Provider Demographics
NPI:1306819883
Name:SUBHAN, MOHAMMAD ABDUL (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:ABDUL
Last Name:SUBHAN
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 1:1739 E BEVERLY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3593
Mailing Address - Country:US
Mailing Address - Phone:928-681-8701
Mailing Address - Fax:928-981-8702
Practice Address - Street 1:1739 E BEVERLY AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3593
Practice Address - Country:US
Practice Address - Phone:928-692-3456
Practice Address - Fax:928-692-7071
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24949207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ371500Medicaid
AZ24949OtherLICENSE
AZ24949OtherLICENSE
AZ371500Medicaid
AZ81862Medicare ID - Type Unspecified