Provider Demographics
NPI:1861674251
Name:SHUJATH ALI KHAN MD PC
Entity type:Organization
Organization Name:SHUJATH ALI KHAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-732-6223
Mailing Address - Street 1:8121 NATIONAL AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-7530
Mailing Address - Country:US
Mailing Address - Phone:405-732-6223
Mailing Address - Fax:
Practice Address - Street 1:8121 NATIONAL AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-7530
Practice Address - Country:US
Practice Address - Phone:405-732-6223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1861674251Medicaid
OK1861674251OtherRAILROAD MEDICARE
OK1861674251OtherBLUE CROSS BLUE SHIELD
OK1861674251OtherRAILROAD MEDICARE