Provider Demographics
NPI:1689864951
Name:KHAN, OMAR ALI (MD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
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 1:405 W COUNTRY CLUB RD
Mailing Address - Street 2:C/O MSO ADMINISTRATION
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5209
Mailing Address - Country:US
Mailing Address - Phone:575-625-1292
Mailing Address - Fax:
Practice Address - Street 1:300 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE # 220
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5202
Practice Address - Country:US
Practice Address - Phone:575-625-1292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2007-0423207Q00000X
NMMD2009-0771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMYIH843397355OtherBLUE CROSS BLUE SHIELD