Provider Demographics
NPI:1588075576
Name:KHAN, MOHAMMED (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:
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 1:474 N LAKE SHORE DR APT 4510
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-6488
Mailing Address - Country:US
Mailing Address - Phone:312-342-4597
Mailing Address - Fax:
Practice Address - Street 1:12935 GREGORY ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2428
Practice Address - Country:US
Practice Address - Phone:708-597-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036141637207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program