Provider Demographics
NPI:1679542914
Name:KHAN, MANSOOR A (MD)
Entity Type:Individual
Prefix:
First Name:MANSOOR
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 1:501 N 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-2618
Mailing Address - Country:US
Mailing Address - Phone:804-704-2344
Mailing Address - Fax:804-452-4549
Practice Address - Street 1:501 N 6TH AVE
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2618
Practice Address - Country:US
Practice Address - Phone:804-704-2344
Practice Address - Fax:804-452-4549
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101228937207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010096413Medicaid
VA010096413Medicaid
VAC09295Medicare PIN