Provider Demographics
NPI:1336339175
Name:KHAN, MAHMOOD (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHMOOD
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MAHMOOD
Other - Middle Name:
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1720 E BEVERLY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3567
Mailing Address - Country:US
Mailing Address - Phone:928-692-1010
Mailing Address - Fax:928-692-7070
Practice Address - Street 1:2002 N STOCKTON HILL RD STE 104
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4698
Practice Address - Country:US
Practice Address - Phone:928-692-1010
Practice Address - Fax:928-692-7070
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24503207QH0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1336339175OtherNPPES
AZ376691Medicaid
1285953950OtherMEDICARE GROUP NPI
AZ376691Medicaid