Provider Demographics
NPI:1639143829
Name:KHANZADA, MOHAMMED A (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:A
Last Name:KHANZADA
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 1:108 N SHACKLEFORD RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-2840
Mailing Address - Country:US
Mailing Address - Phone:501-712-2571
Mailing Address - Fax:
Practice Address - Street 1:2100 N STATE LINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-3583
Practice Address - Country:US
Practice Address - Phone:844-215-0731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD058177L174400000X
MN65023207L00000X
ARE2108207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001717388Medicaid
PA001717388Medicaid
PA021434FEVMedicare ID - Type Unspecified