Healthcare Provider Details

I. General information

NPI: 1164919783
Provider Name (Legal Business Name): DEEPAK KHANNA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S 54TH ST
PHILADELPHIA PA
19143-1900
US

IV. Provider business mailing address

5 LIPNICK LN
EDISON NJ
08820-1955
US

V. Phone/Fax

Practice location:
  • Phone: 215-748-9707
  • Fax: 215-748-9708
Mailing address:
  • Phone: 732-343-5242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS021567
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: