Provider Demographics
NPI:1104841147
Name:KHAN, MOHAMMAD MUSHTAQ (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:MUSHTAQ
Last Name:KHAN
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 1:1025 W 24TH ST
Mailing Address - Street 2:SUITE #27
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8366
Mailing Address - Country:US
Mailing Address - Phone:928-344-9000
Mailing Address - Fax:928-344-9002
Practice Address - Street 1:1025 W 24TH ST
Practice Address - Street 2:SUITE #27
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8366
Practice Address - Country:US
Practice Address - Phone:928-344-9000
Practice Address - Fax:928-344-9002
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13786207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ222860OtherAHCCCS
AZAZ0387310OtherBLUECROSS BLUESHIELD
AZAZ0387310OtherBLUECROSS BLUESHIELD
AZZ 75662Medicare ID - Type Unspecified