Provider Demographics
NPI:1790712784
Name:KHAZNADAR, MOHAMEDAOUF (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMEDAOUF
Middle Name:
Last Name:KHAZNADAR
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 1:1901 MEDI PARK DR
Mailing Address - Street 2:SUITE 124
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-2110
Mailing Address - Country:US
Mailing Address - Phone:806-359-9866
Mailing Address - Fax:806-359-1180
Practice Address - Street 1:1901 MEDI PARK DR
Practice Address - Street 2:SUITE 124
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2110
Practice Address - Country:US
Practice Address - Phone:806-359-9866
Practice Address - Fax:806-359-1180
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1504207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110190468OtherRAILROAD MEDICARE
TX135305411Medicaid
TX135305413Medicaid
TX135306406Medicaid
0045DVOtherBLUE CROSS
TX135305412Medicaid
752836096OtherTAX ID #
116723101OtherFIRSTCARE
TX8L5764Medicare PIN
752836096OtherTAX ID #
TX135306406Medicaid
TX135305413Medicaid