Provider Demographics
NPI:1881775708
Name:IKRAM, KHAWAJA HAROUN (DO)
Entity type:Individual
Prefix:DR
First Name:KHAWAJA
Middle Name:HAROUN
Last Name:IKRAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4058
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-4058
Mailing Address - Country:US
Mailing Address - Phone:517-784-1495
Mailing Address - Fax:517-784-1051
Practice Address - Street 1:200 SUMMIT AVE STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2465
Practice Address - Country:US
Practice Address - Phone:517-784-1495
Practice Address - Fax:517-784-1051
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010754207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3059100Medicaid
MI5380081OtherBCBS
MI3059100Medicaid
MI5380081OtherBCBS