Healthcare Provider Details

I. General information

NPI: 1407030950
Provider Name (Legal Business Name): PRASHANT KHULLAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-578-5880
  • Fax: 859-578-5881
Mailing address:
  • Phone: 859-578-5880
  • Fax: 859-578-5881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberRR7990
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number40787
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberTP202
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number55958
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: