Provider Demographics
NPI:1790710481
Name:KHAN, MOHAMMAD I (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:I
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-361-8496
Mailing Address - Fax:
Practice Address - Street 1:1460 BLUEGRASS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1272
Practice Address - Country:US
Practice Address - Phone:502-361-8496
Practice Address - Fax:502-361-3377
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39426207RH0000X, 207RX0202X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP0044417OtherRAILROAD MEDICARE
KY000000481761OtherANTHEM
KY7100010560Medicaid
KY000000566611OtherANTHEM BCBS
KYI61737Medicare UPIN
KY0998813Medicare PIN
KY7100010560Medicaid
KY00280067Medicare PIN