Provider Demographics
NPI:1770532020
Name:KHAN, MANSUR A (MD)
Entity type:Individual
Prefix:DR
First Name:MANSUR
Middle Name:A
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1040
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-1040
Mailing Address - Country:US
Mailing Address - Phone:623-907-8686
Mailing Address - Fax:623-907-8440
Practice Address - Street 1:9305 W THOMAS RD
Practice Address - Street 2:SUITE 355
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3328
Practice Address - Country:US
Practice Address - Phone:623-907-8686
Practice Address - Fax:623-907-8440
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34541207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ024635Medicaid
AZ2Z7084OtherHEALTH NET
AZZ111396Medicare PIN
AZ024635Medicaid