Provider Demographics
NPI:1508850116
Name:KHAN, MUHAMMAD AZAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MUHAMMAD
Middle Name:AZAM
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 1:3636 STOCKTON HILL RD
Mailing Address - Street 2:N/A
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0514
Mailing Address - Country:US
Mailing Address - Phone:928-757-4398
Mailing Address - Fax:928-757-7224
Practice Address - Street 1:3636 STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-0514
Practice Address - Country:US
Practice Address - Phone:928-757-3636
Practice Address - Fax:928-757-3622
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9994208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ214320Medicaid
AZWCJAZ01OtherMEDICARE PTAN
AZWCJAZ01OtherMEDICARE PTAN