Provider Demographics
NPI:1104873652
Name:KHAN, MUSTAFA (MD)
Entity type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:
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 1:1218 W KILBOURN AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1325
Mailing Address - Country:US
Mailing Address - Phone:414-276-6000
Mailing Address - Fax:414-276-1758
Practice Address - Street 1:1218 W KILBOURN AVE STE 301
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1325
Practice Address - Country:US
Practice Address - Phone:414-276-6000
Practice Address - Fax:414-276-1758
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.096184207XS0117X, 207XS0117X
NJ25MA08456800207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2746863Medicaid
OH2746863Medicaid