Healthcare Provider Details

I. General information

NPI: 1063788370
Provider Name (Legal Business Name): MAZHAR AHMED KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N STATE ST
GREENFIELD IN
46140-1270
US

IV. Provider business mailing address

1 MEMORIAL SQ STE 50
GREENFIELD IN
46140-1357
US

V. Phone/Fax

Practice location:
  • Phone: 317-462-5544
  • Fax: 317-468-6268
Mailing address:
  • Phone: 317-468-6270
  • Fax: 317-468-6268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberQ4614
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: