Provider Demographics
NPI:1154414431
Name:KHAN, MEHTAB A (MD, MPH)
Entity type:Individual
Prefix:
First Name:MEHTAB
Middle Name:A
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-6070
Mailing Address - Country:US
Mailing Address - Phone:765-935-0629
Mailing Address - Fax:
Practice Address - Street 1:320S 48TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-6070
Practice Address - Country:US
Practice Address - Phone:765-935-0629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067816A2084P0800X
IN010678162084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200995260Medicaid
000000731352OtherANTHEM
OH3109166Medicaid
000000731352OtherANTHEM