=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588819312
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KANWAL KHANNA, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2008
-----------------------------------------------------
Last Update Date | 11/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1429 COLLEGE AVE SUITE M
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-4057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-524-2041
-----------------------------------------------------
Fax | 209-524-2394
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1429 COLLEGE AVENUE SUITE M
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-4046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-524-2041
-----------------------------------------------------
Fax | 209-524-2394
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KANWAL KHANNA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 209-524-2041
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | G58069
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------