Healthcare Provider Details

I. General information

NPI: 1497700330
Provider Name (Legal Business Name): SANJAY K KHOLWADWALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10501 GOLF COURSE RD NW
ALBUQUERQUE NM
87114-5019
US

IV. Provider business mailing address

10806 PINO AVE NE
ALBUQUERQUE NM
87122-3432
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-2050
  • Fax: 505-727-2049
Mailing address:
  • Phone: 505-681-9131
  • Fax: 505-821-3773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number97-288
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: