Provider Demographics
NPI:1740970664
Name:KHAN, MUHAMMAD OWAIS
Entity type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:OWAIS
Last Name:KHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MEMORIAL DR OFC BLDGB
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 MEMORIAL DR OFC BLDGB
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6705
Practice Address - Country:US
Practice Address - Phone:618-219-5644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.081343207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine