Provider Demographics
NPI:1164508370
Name:S ISMAIL BOKHARI, M.D., P.C.
Entity Type:Organization
Organization Name:S ISMAIL BOKHARI, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYED PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHMOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-757-1333
Mailing Address - Street 1:1720 E BEVERLY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3567
Mailing Address - Country:US
Mailing Address - Phone:928-757-1333
Mailing Address - Fax:928-757-2367
Practice Address - Street 1:1720 E BEVERLY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3567
Practice Address - Country:US
Practice Address - Phone:928-757-1333
Practice Address - Fax:928-757-2367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24503207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ376691Medicaid
AZZ67181Medicare PIN
AZG43767Medicare UPIN