MEDICARE: ARYA KHATIWODA D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	5101020314	MI

General Provider Information

NPI Number	:	1609213636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ARYA KHATIWODA D.O.

Provider Business Mailing Address
First Line	:	804 SERVICE RD
Second Line	:	# A109F
City	:	EAST LANSING
State	:	MI
Zip	:	48824-7015
Country	:	US
Telephone Number	:	517-884-2976
Fax Number	:	517-432-3928

Provider Business Practice Location Address
First Line	:	2900 HANNAH BLVD STE 104
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48823-5380
Country	:	US
Telephone Number	:	517-364-8118
Fax Number	:	517-364-8119

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2013
Last Update Date	:	10/25/2018

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