Provider Demographics
NPI:1548450539
Name:KHAN, AISHA (MD)
Entity type:Individual
Prefix:
First Name:AISHA
Middle Name:
Last Name:KHAN
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 1:11751 ALTA VISTA RD
Mailing Address - Street 2:STE 103
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6441
Mailing Address - Country:US
Mailing Address - Phone:972-691-4100
Mailing Address - Fax:
Practice Address - Street 1:11751 ALTA VISTA RD
Practice Address - Street 2:STE 103
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6441
Practice Address - Country:US
Practice Address - Phone:972-691-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN8672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281353702OtherMEDICAID EP1
TX281356001Medicaid
TX281353701OtherMEDICAID GROUP TPI