Provider Demographics
NPI:1730107178
Name:KHALID, MAHMOOD A (MD)
Entity Type:Individual
Prefix:
First Name:MAHMOOD
Middle Name:A
Last Name:KHALID
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 77000
Mailing Address - Street 2:DEPT 160901
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-1609
Mailing Address - Country:US
Mailing Address - Phone:248-857-7515
Mailing Address - Fax:734-677-7407
Practice Address - Street 1:461 W HURON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1601
Practice Address - Country:US
Practice Address - Phone:248-857-7515
Practice Address - Fax:248-857-7524
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0354992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2707671Medicaid
MICI8050OtherMEDICARE RR GROUP
MI4626456Medicaid
MI0E01133OtherBCBS OF MI GROUP
MI4626456Medicaid
MI0M74500Medicare PIN
MIOF34966001Medicare ID - Type Unspecified
MI2707671Medicaid