Healthcare Provider Details

I. General information

NPI: 1568596336
Provider Name (Legal Business Name): MAHRUKH KHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7491 BIG BEND BLVD.
ST. LOUIS MO
63119
US

IV. Provider business mailing address

PO BOX 2153 DEPT #30704
BIRMINGHAM AL
35287-9257
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-3038
  • Fax: 314-961-6731
Mailing address:
  • Phone: 314-961-3038
  • Fax: 314-961-6731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number112340
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: