Provider Demographics
NPI:1407920333
Name:KHAN, MUSHTAQ AHMAD (MD)
Entity Type:Individual
Prefix:DR
First Name:MUSHTAQ
Middle Name:AHMAD
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 1:1025 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-1329
Mailing Address - Country:US
Mailing Address - Phone:213-623-2225
Mailing Address - Fax:213-765-4150
Practice Address - Street 1:1025 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-1329
Practice Address - Country:US
Practice Address - Phone:213-623-2225
Practice Address - Fax:213-765-4150
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA051034207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F41197Medicare UPIN