Provider Demographics
NPI:1588668941
Name:KHAN, MIRKUTUB M (MD)
Entity type:Individual
Prefix:DR
First Name:MIRKUTUB
Middle Name:M
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KUTUB
Other - Middle Name:M
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4650 JEFFERSON LN NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2127
Mailing Address - Country:US
Mailing Address - Phone:505-727-7900
Mailing Address - Fax:505-727-7942
Practice Address - Street 1:4650 JEFFERSON LN NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2127
Practice Address - Country:US
Practice Address - Phone:505-727-7900
Practice Address - Fax:505-727-7942
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77-1992085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM253823OtherAHCCCS
NM920003012OtherMEDICARE RAILROAD
NM00023176Medicaid
NMD35752Medicare UPIN
NM920003012OtherMEDICARE RAILROAD
NM253823OtherAHCCCS
NMD35752Medicare UPIN
NMRADIO102Medicare PIN