Basic Information
| Provider Information | |||||||||
| NPI: | 1114964756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHANDELWAL | ||||||||
| FirstName: | PANKAJ | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9724379605 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 N WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797615413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323358275 | ||||||||
| FaxNumber: | 4323340687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 07/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | J3514 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 000J7105 | 05 | NM | MEDICAID | 135931704 | 05 | TX | MEDICAID | 135931703 | 05 | TX | MEDICAID | 135931702 | 05 | TX | MEDICAID | 135931706 | 05 | TX | MEDICAID | 830001029 | 01 | TX | RAILROAD | OTHER | 135931705 | 05 | TX | MEDICAID | 135931709 | 05 | TX | MEDICAID | 8R1486 | 01 | TX | BLUE CROSS TX | OTHER | 135931701 | 05 | TX | MEDICAID |