Provider Demographics
NPI:1477592905
Name:KHAN, MONIRUZZAMAN (MD)
Entity Type:Individual
Prefix:
First Name:MONIRUZZAMAN
Middle Name:
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 1:4402 E 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-2590
Mailing Address - Country:US
Mailing Address - Phone:586-200-0611
Mailing Address - Fax:586-381-7055
Practice Address - Street 1:4402 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2590
Practice Address - Country:US
Practice Address - Phone:586-200-0611
Practice Address - Fax:586-381-7055
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK057394208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
0634011OtherBCBS
G97370OtherHEALTH ALLIANCE PLAN
1215BOtherCAPE HEALTH PLAN
15486OtherHEALTH PLAN OF MICH
MI414952410Medicaid
120911OtherCARE CHOICE
6251OtherTOTAL HEALTH
P105053OtherBCN
C7543OtherMCARE
15486OtherHEALTH PLAN OF MICH
G97370OtherHEALTH ALLIANCE PLAN
6251OtherTOTAL HEALTH
G97370Medicare UPIN