Provider Demographics
NPI:1023087368
Name:KHAN, MUBASHIR A (MD)
Entity type:Individual
Prefix:
First Name:MUBASHIR
Middle Name:A
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4720 PUDDLEDOCK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23875-1237
Mailing Address - Country:US
Mailing Address - Phone:804-452-4546
Mailing Address - Fax:804-452-4549
Practice Address - Street 1:4720 PUDDLEDOCK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1237
Practice Address - Country:US
Practice Address - Phone:804-452-4546
Practice Address - Fax:804-452-4549
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA01012306542084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007104545Medicaid
C08332OtherMEDICARE GROUP NUMBER
VA007104545Medicaid
VA007104545Medicaid