Provider Demographics
NPI:1871639237
Name:KHAN, MUBBASHIR MUZZAMMIL (MD)
Entity Type:Individual
Prefix:MR
First Name:MUBBASHIR
Middle Name:MUZZAMMIL
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 1:410 SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2002
Mailing Address - Country:US
Mailing Address - Phone:912-260-1206
Mailing Address - Fax:
Practice Address - Street 1:410 SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2002
Practice Address - Country:US
Practice Address - Phone:912-260-1206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0543272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003120037DMedicaid
GAGRP3993Medicare PIN
GAH59688Medicare UPIN
GA26BDJRZMedicare ID - Type Unspecified