Provider Demographics
NPI:1679703797
Name:KHAN, MOHAMMED MUDASSER (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:MUDASSER
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 1:9792 SCHAFFNER DR
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-0079
Mailing Address - Country:US
Mailing Address - Phone:516-784-6077
Mailing Address - Fax:309-353-1481
Practice Address - Street 1:1954 GATEWAY CENTER DR
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-9303
Practice Address - Country:US
Practice Address - Phone:516-784-6077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036130956207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine