=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821905811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KHAKWANI MEDICAL CORPORATION, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2026
-----------------------------------------------------
Last Update Date | 08/25/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7425-B S. RAINBOW BLVD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-208-9378
-----------------------------------------------------
Fax | 702-302-4038
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 660048
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75266-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-820-5713
-----------------------------------------------------
Fax | 775-467-2466
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | SAM RICHARD ROY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-868-0730
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------