Provider Demographics
NPI:1063788370
Name:KHAN, MAZHAR AHMED (MD)
Entity type:Individual
Prefix:
First Name:MAZHAR
Middle Name:AHMED
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 1:1 MEMORIAL SQ STE 50
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-1357
Mailing Address - Country:US
Mailing Address - Phone:317-468-6270
Mailing Address - Fax:317-468-6268
Practice Address - Street 1:801 N STATE ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1270
Practice Address - Country:US
Practice Address - Phone:317-462-5544
Practice Address - Fax:317-468-6268
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXQ4614207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program