Healthcare Provider Details

I. General information

NPI: 1861497372
Provider Name (Legal Business Name): SHISHIR KUMAR KHETAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SEVEN LOCKS RD STE 111
ROCKVILLE MD
20854-2957
US

IV. Provider business mailing address

PO BOX 79632
BALTIMORE MD
21279-0632
US

V. Phone/Fax

Practice location:
  • Phone: 301-762-5020
  • Fax: 301-294-7569
Mailing address:
  • Phone: 301-762-5020
  • Fax: 301-309-3783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME148198
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0061630
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number73702
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: