Provider Demographics
NPI:1629047857
Name:KHAN, MUJTABA A (MD)
Entity Type:Individual
Prefix:
First Name:MUJTABA
Middle Name:A
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 1:7111 N MAIN ST
Mailing Address - Street 2:STE 50
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-2558
Mailing Address - Country:US
Mailing Address - Phone:937-424-5986
Mailing Address - Fax:937-424-5989
Practice Address - Street 1:7111 N MAIN ST
Practice Address - Street 2:STE 50
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2558
Practice Address - Country:US
Practice Address - Phone:937-424-5986
Practice Address - Fax:937-424-5989
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.072389207RC0000X, 207UN0901X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2029281Medicaid
OH060051912OtherRAILROAD MEDICARE
OHG61300Medicare UPIN
OHH461700Medicare PIN
OH060051912OtherRAILROAD MEDICARE