Provider Demographics
NPI:1164780284
Name:KHAN, MUHAMMAD OMER (MD)
Entity Type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:OMER
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 1:1 BOSTON MEDICAL CTR PL # 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2908
Mailing Address - Country:US
Mailing Address - Phone:617-414-4929
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL # 1
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2908
Practice Address - Country:US
Practice Address - Phone:617-414-4929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA264661207P00000X
IN11016464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY291124865OtherDRIVING LICENSE