Provider Demographics
NPI:1942241948
Name:KHAN, M O (MD)
Entity Type:Individual
Prefix:MR
First Name:M
Middle Name:O
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 1:55 IRVING STREET
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812
Mailing Address - Country:US
Mailing Address - Phone:803-259-5150
Mailing Address - Fax:803-259-9078
Practice Address - Street 1:55 IRVING STREET
Practice Address - Street 2:
Practice Address - City:BARNWELL
Practice Address - State:SC
Practice Address - Zip Code:29812
Practice Address - Country:US
Practice Address - Phone:803-259-5150
Practice Address - Fax:803-259-9078
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8422208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC084223Medicaid
SC084223Medicaid
D90652Medicare UPIN