Healthcare Provider Details

I. General information

NPI: 1265462139
Provider Name (Legal Business Name): SURESH K KHETAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7610 CARROLL AVE SUITE 260
TAKOMA PARK MD
20912
US

IV. Provider business mailing address

PO BOX 7398
LANGLEY PARK MD
20787-7398
US

V. Phone/Fax

Practice location:
  • Phone: 301-891-9770
  • Fax: 301-891-1620
Mailing address:
  • Phone: 301-963-3456
  • Fax: 301-963-0424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD55403
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: