Provider Demographics
NPI:1891765350
Name:KHAN, MUMTAJ A (MD)
Entity Type:Individual
Prefix:
First Name:MUMTAJ
Middle Name:A
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 1:11879 QUARTERHORSE CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45249-1280
Mailing Address - Country:US
Mailing Address - Phone:513-257-3882
Mailing Address - Fax:
Practice Address - Street 1:11879 QUARTERHORSE CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-1280
Practice Address - Country:US
Practice Address - Phone:513-257-3882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-1818 K207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0404600Medicaid
OH000000264612OtherBLUECROSS BLUESHIELD
OH0404600Medicaid
OH000000264612OtherBLUECROSS BLUESHIELD