Provider Demographics
NPI:1194792382
Name:KHAN, MOHAMMAD A (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:A
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 1:754 CHEROKEE ST NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7209
Mailing Address - Country:US
Mailing Address - Phone:770-428-8118
Mailing Address - Fax:
Practice Address - Street 1:754 CHEROKEE ST NE
Practice Address - Street 2:SUITE A
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7209
Practice Address - Country:US
Practice Address - Phone:770-428-8118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042314207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00728307NMedicaid
GA582587211OtherTAX ID
GA582587211OtherTAX ID
GA08BDPXFMedicare PIN