1417901604 NPI number — SHAZIB N. KHAWAJA MD

Table of content: SHAZIB N. KHAWAJA MD (NPI 1417901604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417901604 NPI number — SHAZIB N. KHAWAJA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHAWAJA
Provider First Name:
SHAZIB
Provider Middle Name:
N.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417901604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 AMBULANCE DR 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARROLLTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30117-3857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-838-8710
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 DIXIE ST
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30117-3818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-836-9326
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  058888 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 058888 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X , with the licence number: 25860 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 009949425 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08537330 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51521327 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 269454900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2510927 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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