Healthcare Provider Details

I. General information

NPI: 1104873652
Provider Name (Legal Business Name): MUSTAFA KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 W KILBOURN AVE STE 301
MILWAUKEE WI
53233-1325
US

IV. Provider business mailing address

1218 W KILBOURN AVE STE 301
MILWAUKEE WI
53233-1325
US

V. Phone/Fax

Practice location:
  • Phone: 414-276-6000
  • Fax: 414-276-1758
Mailing address:
  • Phone: 414-276-6000
  • Fax: 414-276-1758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number35.096184
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: