Basic Information
| Provider Information | |||||||||
| NPI: | 1619186228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHANDELWAL | ||||||||
| FirstName: | NIRAJ | ||||||||
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| Credential: | MD, MHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 COLLIER RD NW | ||||||||
| Address2: | SUITE 4075 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043553200 | ||||||||
| FaxNumber: | 4043559316 | ||||||||
| Practice Location | |||||||||
| Address1: | 1265 HIGHWAY 54 W | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302144548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707193240 | ||||||||
| FaxNumber: | 7707193241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 07/09/2012 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RG0100X | 57.017193 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 67781 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | BP1-0022713 | 01 | INSTITUTIONAL PERMIT | OTHER |