Provider Demographics
NPI:1447993142
Name:KHAN, MAAZULLAH (DPM)
Entity type:Individual
Prefix:
First Name:MAAZULLAH
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 S OAK ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2919
Mailing Address - Country:US
Mailing Address - Phone:574-341-9697
Mailing Address - Fax:
Practice Address - Street 1:425 W 5TH ST
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-2405
Practice Address - Country:US
Practice Address - Phone:574-341-9697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program