Provider Demographics
NPI:1851409122
Name:KHAN, MUKARRAM ALI (DO)
Entity Type:Individual
Prefix:
First Name:MUKARRAM
Middle Name:ALI
Last Name:KHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:200 MEDICAL CENTER DR STE 325
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45005-5178
Practice Address - Country:US
Practice Address - Phone:513-708-7620
Practice Address - Fax:513-705-7065
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.008823207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100217010Medicaid
OH000000488997OtherANTHEM
OH2679703Medicaid
OH7001837OtherAETNA
OH2679703Medicaid