Provider Demographics
NPI:1124217286
Name:KHAN, MOHAMMAD MAHMUD (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:MAHMUD
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 1:498 W BOUGHTON ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOLINGBROOOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1925
Mailing Address - Country:US
Mailing Address - Phone:630-771-1630
Mailing Address - Fax:630-771-1631
Practice Address - Street 1:498 W BOUGHTON ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:BOLINGBROOOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1925
Practice Address - Country:US
Practice Address - Phone:630-771-1630
Practice Address - Fax:630-771-1631
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-109931208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109931Medicaid