Provider Demographics
NPI:1578590212
Name:KHAN, MOHAMMAD KHALID (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:KHALID
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 1:6594 RUTHERFORD DR
Mailing Address - Street 2:
Mailing Address - City:MACUNGIE
Mailing Address - State:PA
Mailing Address - Zip Code:18062-8049
Mailing Address - Country:US
Mailing Address - Phone:717-329-0712
Mailing Address - Fax:610-366-1063
Practice Address - Street 1:4949 LIBERTY LN
Practice Address - Street 2:SUITE 140
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18106-9014
Practice Address - Country:US
Practice Address - Phone:717-329-0712
Practice Address - Fax:610-366-1063
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056299L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018758410004Medicaid
PA001356565OtherPA BLUE SHIELD
PA50044330OtherCAPITAL BLUE CROSS
PA50044330OtherCAPITAL BLUE CROSS
PAFD7908Medicare UPIN