Provider Demographics
NPI:1013907328
Name:KHAN, MOHAMMED JAMIL AHMED (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMED JAMIL
Middle Name:AHMED
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 1:1206 RICHARDSON ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3549
Mailing Address - Country:US
Mailing Address - Phone:810-984-4340
Mailing Address - Fax:810-984-2303
Practice Address - Street 1:1206 RICHARDSON ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3549
Practice Address - Country:US
Practice Address - Phone:810-984-4340
Practice Address - Fax:810-984-2303
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031939207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2108970Medicaid
E38084Medicare UPIN
0740729Medicare ID - Type Unspecified