Provider Demographics
NPI:1023805736
Name:KHAN, MOHAMADOMAR KHALID (DPT)
Entity type:Individual
Prefix:
First Name:MOHAMADOMAR
Middle Name:KHALID
Last Name:KHAN
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6380 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2255
Mailing Address - Country:US
Mailing Address - Phone:786-826-2183
Mailing Address - Fax:
Practice Address - Street 1:17000 EXECUTIVE PLAZA DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2793
Practice Address - Country:US
Practice Address - Phone:313-792-8350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501303675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist