Provider Demographics
NPI:1508022740
Name:KHANI, MOHUMMED RADWAN (MD)
Entity type:Individual
Prefix:DR
First Name:MOHUMMED
Middle Name:RADWAN
Last Name:KHANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MOHUMMED RADWAN
Other - Middle Name:
Other - Last Name:KHANI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:252 MEMORIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546
Mailing Address - Country:US
Mailing Address - Phone:347-820-4943
Mailing Address - Fax:
Practice Address - Street 1:255 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6333
Practice Address - Country:US
Practice Address - Phone:347-820-4943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD449711208600000X, 208C00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program