=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871595942
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MUKUL KHANDELWAL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2005
-----------------------------------------------------
Last Update Date | 08/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8109 RITCHIE HWY
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21122-6917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-590-8920
-----------------------------------------------------
Fax | 410-553-2345
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 502 PINEFIELD DR
-----------------------------------------------------
City | SEVERNA PARK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21146-2320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-590-8920
-----------------------------------------------------
Fax | 410-553-2345
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | D0052387
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------