Provider Demographics
NPI:1649442385
Name:KHAN, SAMEENA WAHEED (MD)
Entity type:Individual
Prefix:
First Name:SAMEENA
Middle Name:WAHEED
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 1:150 E SWAN ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37033-1446
Mailing Address - Country:US
Mailing Address - Phone:931-729-3091
Mailing Address - Fax:931-729-0809
Practice Address - Street 1:150 E SWAN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37033-1446
Practice Address - Country:US
Practice Address - Phone:931-729-3091
Practice Address - Fax:931-729-0809
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001615207R00000X
TNMD43967207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510125Medicaid
TN3002528OtherMEDICARE PTAN