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
State | License ID | Taxonomies |
---|---|---|
LA | 15427R | 207PE0004X, 207PP0204X, 207QA0401X, 207QA0505X, 208000000X, 2080P0207X, 324500000X |
MD | D0064698 | 208000000X, 2080N0001X, 2080P0207X, 208M00000X |
DE | C1-0008136 | 2080A0000X, 2080P0008X, 208000000X |
PA | MD429242 | 324500000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | |
No | 207PE0004X | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
No | 207PP0204X | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
No | 207QA0401X | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
No | 207QA0505X | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
No | 2080A0000X | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No | 2080N0001X | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
No | 2080P0008X | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities |
No | 2080P0207X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | |
No | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
DE | 1000040965 | Medicaid |