1770583601 NPI number — DR. RAJAN KHOSLA M.D.

Table of content: DR. RAJAN KHOSLA M.D. (NPI 1770583601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770583601 NPI number — DR. RAJAN KHOSLA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHOSLA
Provider First Name:
RAJAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770583601
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11225 N 28TH DR STE B210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85029-5610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-699-2996
Provider Business Mailing Address Fax Number:
480-361-6917

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3930 S ALMA SCHOOL RD STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85248-4510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-542-7000
Provider Business Practice Location Address Fax Number:
480-542-7500
Provider Enumeration Date:
07/21/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  32972 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Z100580 . This is a "MEDICARE PIN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0766700 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 2Z1750 . This is a "HEALTHNET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 523440 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".