1043364656 NPI number — DR. SANJIV K KHULLAR M.D.

Table of content: DR. SANJIV K KHULLAR M.D. (NPI 1043364656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043364656 NPI number — DR. SANJIV K KHULLAR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHULLAR
Provider First Name:
SANJIV
Provider Middle Name:
K
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:
1043364656
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2726 FULTON DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44718-3506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-455-5011
Provider Business Mailing Address Fax Number:
330-588-7127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2726 FULTON DR NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44718-3506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-455-5011
Provider Business Practice Location Address Fax Number:
330-588-7127
Provider Enumeration Date:
01/22/2007

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:  35076082 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2217260 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100238 . This is a "KAISER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2177960 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0400049 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100013229 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000126859 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




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