MEDICARE: IJAZ MOHAMMAD 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	174400000X	Specialist	34065-020	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952434011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IJAZ MOHAMMAD KHAN M.D.

Provider Business Mailing Address
First Line	:	3046 S 13TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-3826
Country	:	US
Telephone Number	:	414-649-9696
Fax Number	:	414-649-9698

Provider Business Practice Location Address
First Line	:	6026 W LISBON AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-2114
Country	:	US
Telephone Number	:	414-334-9715
Fax Number	:

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

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/08/2007

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