Healthcare Provider Details

I. General information

NPI: 1639223308
Provider Name (Legal Business Name): SANJIV KHETARPAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4665 BELPAR ST NW
CANTON OH
44718
US

IV. Provider business mailing address

PO BOX 36329
CANTON OH
44735
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-1480
  • Fax: 330-493-6805
Mailing address:
  • Phone: 330-493-1480
  • Fax: 330-493-6805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35063232
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: