Provider Demographics
NPI:1386098440
Name:KHAN, MUDASSAR (DO)
Entity type:Individual
Prefix:
First Name:MUDASSAR
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 RIVERCHASE DR
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867
Mailing Address - Country:US
Mailing Address - Phone:334-732-3022
Mailing Address - Fax:
Practice Address - Street 1:613 ELIZABETH ST STE 804
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2231
Practice Address - Country:US
Practice Address - Phone:361-902-4343
Practice Address - Fax:361-902-6000
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2024-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT8572207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery