Provider Demographics
NPI:1205452828
Name:KHAN, MOHAMMAD AHMAD (MD)
Entity type:Individual
Prefix:MR
First Name:MOHAMMAD
Middle Name:AHMAD
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 1:2649 SOUTH ROAD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601
Mailing Address - Country:US
Mailing Address - Phone:845-790-1317
Mailing Address - Fax:
Practice Address - Street 1:2649 SOUTH ROAD
Practice Address - Street 2:SUITE 104
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601
Practice Address - Country:US
Practice Address - Phone:845-790-1317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2024-08-27
Deactivation Date:2022-01-17
Deactivation Code:
Reactivation Date:2022-02-03
Provider Licenses
StateLicense IDTaxonomies
TXU2532207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty