Provider Demographics
NPI:1508834599
Name:KHAN, MAHBOOB ALI (MD)
Entity Type:Individual
Prefix:
First Name:MAHBOOB
Middle Name:ALI
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 1:3571 W WHEATLAND RD
Mailing Address - Street 2:STE 101
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3461
Mailing Address - Country:US
Mailing Address - Phone:972-274-5555
Mailing Address - Fax:972-274-5563
Practice Address - Street 1:3571 W WHEATLAND RD
Practice Address - Street 2:STE 101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3461
Practice Address - Country:US
Practice Address - Phone:972-274-5555
Practice Address - Fax:972-274-5563
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD426847207R00000X, 208M00000X
AL28163207R00000X
TXQ4160207RN0300X, 207R00000X
OH35.095158208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051541255OtherBLUE CROSS
PA819381OtherFIRST PRIORITY HEALTH
AL051541252OtherBLUE CROSS
AL009910049Medicaid
AL009910051Medicaid
PAI38194OtherHEALTHAMERICA
PAP00244719OtherRAILROAD MEDICARE
PA1751916OtherHIGHMARK BLUE SHIELD
AL009910050Medicaid
PA101349604Medicaid
AL051541253OtherBLUE CROSS
PA7711714OtherAETNA
PA093658Medicare ID - Type Unspecified
AL009910051Medicaid
AL051541252OtherBLUE CROSS
PAP00244719OtherRAILROAD MEDICARE