Basic Information
| Provider Information | |||||||||
| NPI: | 1225347727 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHANDELWAL | ||||||||
| FirstName: | PRIYANK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 BERGEN ST RM 1205 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071073000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739720037 | ||||||||
| FaxNumber: | 9739720743 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 BERGEN ST # 8100 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739722323 | ||||||||
| FaxNumber: | 9739722333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2010 | ||||||||
| LastUpdateDate: | 11/20/2018 | ||||||||
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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 | 2084V0102X | 25MA10382600 | NJ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 2084N0400X | 25MA10382600 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0653543 | 05 | NJ | MEDICAID |