Provider Demographics
NPI:1306948435
Name:KHAN, MUKHTAR AHMAD (MD)
Entity type:Individual
Prefix:
First Name:MUKHTAR
Middle Name:AHMAD
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 1:25779 KELLY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4973
Mailing Address - Country:US
Mailing Address - Phone:586-774-0700
Mailing Address - Fax:586-774-9841
Practice Address - Street 1:25779 KELLY RD
Practice Address - Street 2:SUITE C
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4973
Practice Address - Country:US
Practice Address - Phone:586-774-0700
Practice Address - Fax:586-774-9841
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK044345207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP41411OtherBCN
MI2898009Medicaid
MIP2856001Medicare ID - Type Unspecified
MIP41411OtherBCN