Provider Demographics
NPI:1639113285
Name:KHAN, MOHAMMAD ALI (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
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 1:266 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-5235
Mailing Address - Country:US
Mailing Address - Phone:302-449-5791
Mailing Address - Fax:443-350-9783
Practice Address - Street 1:111 W HIGH ST STE 307
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-8617
Practice Address - Country:US
Practice Address - Phone:302-449-5791
Practice Address - Fax:443-350-9783
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15427R207PE0004X, 207PP0204X, 207QA0401X, 207QA0505X, 208000000X, 2080P0207X, 324500000X
MDD0064698208000000X, 2080N0001X, 2080P0207X, 208M00000X
DEC1-00081362080A0000X, 2080P0008X, 208000000X
PAMD429242324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000040965Medicaid