Provider Demographics
NPI:1740289917
Name:KHURSHID, IMTIAZ (MD)
Entity type:Individual
Prefix:
First Name:IMTIAZ
Middle Name:
Last Name:KHURSHID
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 1:12821 OAK HILL AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-2940
Mailing Address - Country:US
Mailing Address - Phone:301-733-0300
Mailing Address - Fax:
Practice Address - Street 1:12821 OAK HILL AVENUE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:301-733-0300
Practice Address - Fax:301-733-5773
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800933207R00000X, 207RP1001X, 207RS0012X
PAMD418913207RP1001X
MDD79693207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG68908Medicare UPIN
061924G0DMedicare PIN
PA061924KUZMedicare ID - Type Unspecified