Healthcare Provider Details

I. General information

NPI: 1851409122
Provider Name (Legal Business Name): MUKARRAM ALI KHAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 COMMONS BLVD STE 130
BEAVERCREEK OH
45431-3840
US

IV. Provider business mailing address

PO BOX 340453
DAYTON OH
45434-0453
US

V. Phone/Fax

Practice location:
  • Phone: 937-280-4970
  • Fax:
Mailing address:
  • Phone: 937-280-4970
  • Fax: 937-630-4578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number34.008823
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number13249
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: