Provider Demographics
NPI:1124083589
Name:KHALIQUE, MOHSIN RIAZ (MD)
Entity type:Individual
Prefix:DR
First Name:MOHSIN
Middle Name:RIAZ
Last Name:KHALIQUE
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 1:5505 SATINLEAF WAY
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-5059
Mailing Address - Country:US
Mailing Address - Phone:925-365-1216
Mailing Address - Fax:
Practice Address - Street 1:5505 SATINLEAF WAY
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94582-5059
Practice Address - Country:US
Practice Address - Phone:925-365-1216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV225902084P0804X
OH350839762084P0804X
CAA 982122084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000218Medicaid
OH2459156Medicaid