Provider Demographics
NPI:1841297611
Name:KHAN, MOHAMED KHALEEM (MD)
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:KHALEEM
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 1:2946 E BANNER GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2165
Mailing Address - Country:US
Mailing Address - Phone:480-256-4500
Mailing Address - Fax:
Practice Address - Street 1:ELM AND CARLTON ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263-0001
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2324102085R0001X
AZ512242085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0000000000OtherMEDICARE
AZ0Medicaid
NY02562861Medicaid
NYH02822Medicare UPIN