MEDICARE: MOHAMMAD MUSSADIQ KHAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	4301097780	MI

General Provider Information

NPI Number	:	1750687786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOHAMMAD MUSSADIQ KHAN M.D.

Provider Business Mailing Address
First Line	:	4245 ALTURA MESA LN NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-5058
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4245 ALTURA MESA LN NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-5058
Country	:	US
Telephone Number	:	505-349-4288
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2011
Last Update Date	:	10/21/2011

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