Healthcare Provider Details

I. General information

NPI: 1265491054
Provider Name (Legal Business Name): KHALID MAHMOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 WEST WASHINGTON STREET
NANTICOKE PA
18634-0514
US

IV. Provider business mailing address

185 FALLBROOK ST
CARBONDALE PA
18407-0514
US

V. Phone/Fax

Practice location:
  • Phone: 570-735-7590
  • Fax: 570-735-3363
Mailing address:
  • Phone: 570-282-1732
  • Fax: 570-282-6529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD425009
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: