Provider Demographics
NPI:1962448688
Name:KHAN, MUHAMMAD IBRAHIM ALI (MD)
Entity Type:Individual
Prefix:DR
First Name:MUHAMMAD
Middle Name:IBRAHIM ALI
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:DEPT L-3652
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-0001
Mailing Address - Country:US
Mailing Address - Phone:740-375-8190
Mailing Address - Fax:740-375-8197
Practice Address - Street 1:1073 HARDING MEMORIAL PKWY STE A
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6364
Practice Address - Country:US
Practice Address - Phone:740-375-8190
Practice Address - Fax:740-375-8197
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084940207QA0505X
OH35.084940207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2499130Medicaid
OH2499130Medicaid