Provider Demographics
NPI:1700016854
Name:KHAN, WAQAS AHMAD (MD)
Entity type:Individual
Prefix:
First Name:WAQAS
Middle Name:AHMAD
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 MARYLAND WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5064
Mailing Address - Country:US
Mailing Address - Phone:615-377-5600
Mailing Address - Fax:949-567-9827
Practice Address - Street 1:2101 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4836
Practice Address - Country:US
Practice Address - Phone:909-881-4520
Practice Address - Fax:909-881-4526
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 108929207R00000X, 208M00000X
IL036133312207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1089290OtherBLUE SHIELD
CA0A1089290OtherBLUE SHIELD