Provider Demographics
NPI:1659791663
Name:KHAN, MOHAMMAD IBRAHEEM (MD)
Entity Type:Individual
Prefix:MR
First Name:MOHAMMAD
Middle Name:IBRAHEEM
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-3518
Mailing Address - Fax:631-444-8886
Practice Address - Street 1:STONY BROOK UFPC PRACTICE 101 NICOLLS ROAD HSC T17-060
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-6999
Practice Address - Country:US
Practice Address - Phone:631-444-3518
Practice Address - Fax:631-444-8886
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305306207RG0100X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program