Provider Demographics
NPI:1255394623
Name:KHAN, MAHMOOD (MD)
Entity type:Individual
Prefix:
First Name:MAHMOOD
Middle Name:
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 1:25880 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-1553
Mailing Address - Country:US
Mailing Address - Phone:313-389-5200
Mailing Address - Fax:313-389-4935
Practice Address - Street 1:25880 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-1553
Practice Address - Country:US
Practice Address - Phone:313-389-5200
Practice Address - Fax:313-389-4935
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031737207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1794888Medicaid
MI08292352OtherBCBSMI
E37404Medicare UPIN
MIP56950001Medicare PIN