Provider Demographics
NPI:1982912655
Name:KHAN, MOHAMMAD KAMRAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:KAMRAN
Last Name:KHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 SILVER CROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9518
Mailing Address - Country:US
Mailing Address - Phone:815-723-4387
Mailing Address - Fax:815-723-4634
Practice Address - Street 1:1890 SILVER CROSS BLVD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451
Practice Address - Country:US
Practice Address - Phone:815-723-4387
Practice Address - Fax:815-723-4634
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11564207T00000X
IL036121940207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE (GROUP)
IL036121940Medicaid
IL206147203OtherMEDICARE (INDIVIDUAL)