Provider Demographics
NPI:1487653838
Name:KHAN, MOHAMMAD AJMAL (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:AJMAL
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:PO BOX 1120
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-4120
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:610 S MAPLE AVE
Practice Address - Street 2:SUITE 3440
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1091
Practice Address - Country:US
Practice Address - Phone:708-660-5017
Practice Address - Fax:708-660-5349
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094223207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094223Medicaid
ILIL1790Medicare PIN
ILK11577Medicare PIN
ILIL1716Medicare PIN
ILIL1790001Medicare PIN
ILDD3356Medicare PIN
IL210183Medicare PIN
ILP00376759Medicare PIN
ILIL1716001Medicare PIN
ILG67259Medicare UPIN