Provider Demographics
NPI:1548337322
Name:KHANAM, DILRUBA (MD)
Entity type:Individual
Prefix:
First Name:DILRUBA
Middle Name:
Last Name:KHANAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 JOHN F. KENNEDY BLVD.
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305
Mailing Address - Country:US
Mailing Address - Phone:201-763-6664
Mailing Address - Fax:201-763-6840
Practice Address - Street 1:1809 JOHN F. KENNEDY BLVD.
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305
Practice Address - Country:US
Practice Address - Phone:201-763-6664
Practice Address - Fax:201-763-6840
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07937600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0123315Medicaid
NJI51007Medicare UPIN
NJ0123315Medicaid
NJ099725Medicare PIN
I51007Medicare UPIN