Healthcare Provider Details

I. General information

NPI: 1700218799
Provider Name (Legal Business Name): MOHAMMED FARHAN KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2013
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 W 15TH ST
CHICAGO IL
60608-1610
US

IV. Provider business mailing address

1500 S CALIFORNIA AVE
CHICAGO IL
60608
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6097
  • Fax:
Mailing address:
  • Phone: 773-257-6097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125064237
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036141255
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: