Provider Demographics
NPI:1275256646
Name:MEHMUD, KHIDAR
Entity Type:Individual
Prefix:
First Name:KHIDAR
Middle Name:
Last Name:MEHMUD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4000
Mailing Address - Country:US
Mailing Address - Phone:612-806-9954
Mailing Address - Fax:320-669-2882
Practice Address - Street 1:3400 1ST ST N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4000
Practice Address - Country:US
Practice Address - Phone:612-806-9954
Practice Address - Fax:320-669-2882
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician