Basic Information
| Provider Information | |||||||||
| NPI: | 1316917214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHANDEKAR | ||||||||
| FirstName: | SURESH | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 744786 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303744786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046168625 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2544 COURT DR STE G | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280543450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048549990 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 200400530 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | MD439742 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 28554 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | BK5850626 | 01 | PA | DEA | OTHER | 285541 | 05 | SC | MEDICAID |