Healthcare Provider Details

I. General information

NPI: 1316917214
Provider Name (Legal Business Name): SURESH KHANDEKAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 03/07/2023
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2544 COURT DR STE G
GASTONIA NC
28054-3450
US

IV. Provider business mailing address

PO BOX 744786
ATLANTA GA
30374-4786
US

V. Phone/Fax

Practice location:
  • Phone: 704-854-9990
  • Fax:
Mailing address:
  • Phone: 704-616-8625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number200400530
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD439742
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number28554
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: