Healthcare Provider Details

I. General information

NPI: 1447430244
Provider Name (Legal Business Name): MANISH PRAVIN KHETANI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55-77 SCHANCK RD STE B-13
FREEHOLD NJ
07728-2964
US

IV. Provider business mailing address

10 TURNBERRY DR
MANALAPAN NJ
07726-9315
US

V. Phone/Fax

Practice location:
  • Phone: 732-612-8485
  • Fax:
Mailing address:
  • Phone: 732-446-1089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA08344200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08344200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: