Provider Demographics
NPI:1700866928
Name:KHAN, MOHAMMAD ALI NAIZUL (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:ALI NAIZUL
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 1:1111 E MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2612
Mailing Address - Country:US
Mailing Address - Phone:602-839-2717
Mailing Address - Fax:602-839-2708
Practice Address - Street 1:1111 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2612
Practice Address - Country:US
Practice Address - Phone:602-839-2717
Practice Address - Fax:602-839-2708
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23104207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ330811Medicaid
Z142717Medicare PIN
AZG05167Medicare UPIN
AZZ140814Medicare PIN
AZ26575Medicare ID - Type Unspecified
AZ26574Medicare ID - Type Unspecified
AZ26577Medicare ID - Type Unspecified
Z142717Medicare PIN
AZZ140814Medicare PIN