Healthcare Provider Details

I. General information

NPI: 1588819312
Provider Name (Legal Business Name): KANWAL KHANNA, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1429 COLLEGE AVE SUITE M
MODESTO CA
95350-4057
US

IV. Provider business mailing address

1429 COLLEGE AVENUE SUITE M
MODESTO CA
95350-4046
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-2041
  • Fax: 209-524-2394
Mailing address:
  • Phone: 209-524-2041
  • Fax: 209-524-2394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberG58069
License Number StateCA

VIII. Authorized Official

Name: DR. KANWAL KHANNA
Title or Position: OWNER
Credential: M.D.
Phone: 209-524-2041