Healthcare Provider Details

I. General information

NPI: 1770833188
Provider Name (Legal Business Name): ASHISH KHANNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2012
Last Update Date: 09/13/2020
Certification Date: 09/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 CLIFTON RD NE
ATLANTA GA
30322-1424
US

IV. Provider business mailing address

1199 PLEASANT VALLEY WAY
WEST ORANGE NJ
05027
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-5512
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number86634
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number1770833188
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: