Provider Demographics
NPI:1104893619
Name:KHAN, MUHAMMAD MUSTAFA (MD)
Entity type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:MUSTAFA
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 1:285 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE- LL6
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2978
Mailing Address - Country:US
Mailing Address - Phone:631-656-6853
Mailing Address - Fax:631-656-6855
Practice Address - Street 1:285 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE- LL6
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2978
Practice Address - Country:US
Practice Address - Phone:631-656-6853
Practice Address - Fax:631-656-6855
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231492208100000X, 2081P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2105284Medicaid
MAA38827Medicare ID - Type Unspecified
MA2105284Medicaid