Provider Demographics
NPI: | 1164463410 |
---|---|
Name: | KHAN, MUKHTAR I (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MUKHTAR |
Middle Name: | I |
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: | 3229 E GENESEE ST |
Mailing Address - Street 2: | JOSLIN CENTER |
Mailing Address - City: | SYRACUSE |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 13214-2016 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3229 E GENESEE ST |
Practice Address - Street 2: | JOSLIN CENTER |
Practice Address - City: | SYRACUSE |
Practice Address - State: | NY |
Practice Address - Zip Code: | 13214-2016 |
Practice Address - Country: | US |
Practice Address - Phone: | 315-464-5726 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-09 |
Last Update Date: | 2009-01-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 213249 | 207R00000X, 207RE0101X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 02161939 | Medicaid | |
NY | G56784 | Medicare UPIN | |
NY | 02161939 | Medicaid | |
NY | 460003301 | Medicare PIN |