Healthcare Provider Details

I. General information

NPI: 1053239020
Provider Name (Legal Business Name): KHAKWANI AND MOHAMMAD MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 N VERRADO WAY STE 108B
BUCKEYE AZ
85396-1868
US

IV. Provider business mailing address

PO BOX 660047
DALLAS TX
75266-2900
US

V. Phone/Fax

Practice location:
  • Phone: 480-499-1539
  • Fax: 480-566-2315
Mailing address:
  • Phone: 702-820-5713
  • Fax: 775-467-2466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SAM RICHARD ROY
Title or Position: MEDICAL CREDENTIALING MANAGER
Credential:
Phone: 469-868-0730