Mohammad Mahmud Khan, MD
Individual provider Active NPI Pediatrics Physician · Bolingbroook, IL
NPI 1124217286 · NPPES record last updated Apr 19, 2010
Key facts
- NPI
- 1124217286
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pediatrics Physician 208000000X
- License
- 036-109931 (IL)
- Practice address
- 498 W Boughton Road
Suite 103
Bolingbroook, IL 60440-1925 - Phone
- (630) 771-1630
- Fax
- (630) 771-1631
- NPI assigned
- Oct 15, 2007
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 036-109931 | IL | MD | Pediatrics Physician |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 036-109931 | IL | Yes |
Addresses
Primary practice location
498 W Boughton Road
Suite 103
Bolingbroook, IL 60440-1925
Mailing address
498 W Boughton Road
Suite 102
Bolingbroook, IL 60440-1925
Phone (630) 771-1630
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 036109931 | Medicaid | IL |
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 19, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.