Healthcare Provider Details

I. General information

NPI: 1659791663
Provider Name (Legal Business Name): MOHAMMAD IBRAHEEM KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STONY BROOK UFPC PRACTICE 101 NICOLLS ROAD HSC T17-060
STONY BROOK NY
11794-6999
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-3518
  • Fax: 631-444-8886
Mailing address:
  • Phone: 631-444-3518
  • Fax: 631-444-8886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number305306
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: