Provider Demographics
NPI:1841436763
Name:AVICENNA MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:AVICENNA MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MUJTABA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI-KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:855-372-5454
Mailing Address - Street 1:PO BOX 132921
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77393-2921
Mailing Address - Country:US
Mailing Address - Phone:855-372-5454
Mailing Address - Fax:936-585-4657
Practice Address - Street 1:504 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2808
Practice Address - Country:US
Practice Address - Phone:855-372-5454
Practice Address - Fax:281-408-4108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-23
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3450208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty