Provider Demographics
NPI:1396953485
Name:KHAN, MOHAMMED ALI (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:ALI
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 1:3212 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6209
Mailing Address - Country:US
Mailing Address - Phone:309-306-1234
Mailing Address - Fax:309-213-9661
Practice Address - Street 1:3212 COURT ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6209
Practice Address - Country:US
Practice Address - Phone:309-306-1234
Practice Address - Fax:309-213-9661
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123108208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09015685OtherBCBS OF IL
IL036123108Medicaid