Provider Demographics
NPI:1073524062
Name:MAHBOOB, NEERAJ (MD)
Entity Type:Individual
Prefix:
First Name:NEERAJ
Middle Name:
Last Name:MAHBOOB
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 1:515 MEMORIAL DR
Mailing Address - Street 2:STE 3
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-9157
Mailing Address - Country:US
Mailing Address - Phone:606-599-0864
Mailing Address - Fax:606-599-0864
Practice Address - Street 1:515 MEMORIAL DR
Practice Address - Street 2:STE 3
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-9157
Practice Address - Country:US
Practice Address - Phone:606-599-0864
Practice Address - Fax:606-599-0869
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36255207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64-023260Medicaid
KY0742701Medicare ID - Type Unspecified
KY64-023260Medicaid