Provider Demographics
NPI:1063617603
Name:KHATTAB, MAHMOUD (MD)
Entity type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:
Last Name:KHATTAB
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 1:9390 BIG HORN BLVD
Mailing Address - Street 2:145
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7980
Mailing Address - Country:US
Mailing Address - Phone:916-691-6666
Mailing Address - Fax:916-691-6668
Practice Address - Street 1:9390 BIG HORN BLVD
Practice Address - Street 2:145
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7980
Practice Address - Country:US
Practice Address - Phone:916-691-6666
Practice Address - Fax:916-691-6668
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50188207R00000X
MI4301092458207R00000X
CAA97693207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I74253Medicare UPIN
MIB26002092Medicare PIN