Basic Information
| Provider Information | |||||||||
| NPI: | 1497932149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHANNA | ||||||||
| FirstName: | PRAVIEN | ||||||||
| MiddleName: | K . | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 VERONICA AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SOMERSET | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088735002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322477444 | ||||||||
| FaxNumber: | 7322475119 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 VERONICA AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SOMERSET | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088735002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322477444 | ||||||||
| FaxNumber: | 7322475119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 03/13/2017 | ||||||||
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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 | 207RC0000X | 264703-1 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 25MA09252100 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 0422088 | 05 | NJ | MEDICAID |