Healthcare Provider Details

I. General information

NPI: 1396941175
Provider Name (Legal Business Name): MASHIUR RAHMAN KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 E 10TH ST
JEFFERSONVILLE IN
47130-7303
US

IV. Provider business mailing address

2420 E 10TH ST
JEFFERSONVILLE IN
47130-7303
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-8248
  • Fax:
Mailing address:
  • Phone: 812-282-8248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number43888
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number43888
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: