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
StateLicense IDTaxonomies
NY213249207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02161939Medicaid
NYG56784Medicare UPIN
NY02161939Medicaid
NY460003301Medicare PIN