Provider Demographics
NPI:1861401127
Name:KHAN, TARIQ ALI (MD)
Entity type:Individual
Prefix:
First Name:TARIQ
Middle Name:ALI
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:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:28 S MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4914
Practice Address - Country:US
Practice Address - Phone:573-331-3350
Practice Address - Fax:573-331-3351
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022009938207RG0100X
MS15809174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR132145001Medicaid
TN3815396Medicaid
MS00118746Medicaid
AR132145001Medicaid
TN3150548OtherBLUE CROSS
MS00118746Medicaid
TN3150548OtherBLUE CROSS
TN3815396Medicaid