Provider Demographics
NPI:1902973985
Name:KHAN, MUMTAZ J (MD)
Entity Type:Individual
Prefix:
First Name:MUMTAZ
Middle Name:J
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:15401 EAST JEFFERSON
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230
Mailing Address - Country:US
Mailing Address - Phone:313-824-4800
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:15401 EAST JEFFERSON
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230
Practice Address - Country:US
Practice Address - Phone:313-824-4800
Practice Address - Fax:313-824-7080
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065423207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI434035010Medicaid
MK065423OtherCHAMPUS-CHAMPUS
700H262260OtherBLUE CROSS-BLUE CROSS
MK065423OtherCOMMERCIAL-COMMERCIAL NUMBER
0H26226034Medicare ID - Type Unspecified
MI434035010Medicaid