Provider Demographics
NPI:1245724749
Name:KHADER, MOHAMMAD ALI (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:ALI
Last Name:KHADER
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 1:12806 W 173RD TER
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66221-7153
Mailing Address - Country:US
Mailing Address - Phone:239-300-3739
Mailing Address - Fax:
Practice Address - Street 1:4000 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-5754
Practice Address - Country:US
Practice Address - Phone:913-588-1422
Practice Address - Fax:913-588-3877
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN26934207R00000X
KS04-46471207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty