Provider Demographics
NPI:1104081900
Name:KHAN, MANSOOR A (DO)
Entity type:Individual
Prefix:DR
First Name:MANSOOR
Middle Name:A
Last Name:KHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:MANSOOR
Other - Middle Name:A
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:9217 101ST AVE
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11416-2316
Mailing Address - Country:US
Mailing Address - Phone:412-452-4262
Mailing Address - Fax:
Practice Address - Street 1:9217 101ST AVE
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11416-2316
Practice Address - Country:US
Practice Address - Phone:412-452-4262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2013-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265529207Q00000X, 208D00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry