Basic Information
Provider Information | |||||||||
NPI: | 1740382233 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KHANNA | ||||||||
FirstName: | ATUL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13808 PROFESSIONAL CENTER DRIVE | ||||||||
Address2: |   | ||||||||
City: | HUNTERSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 280787948 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7043774009 | ||||||||
FaxNumber: | 4234311811 | ||||||||
Practice Location | |||||||||
Address1: | 2015 RANDOLPH ROAD | ||||||||
Address2: | SUITE 208 | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282071200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7043774009 | ||||||||
FaxNumber: | 4234311811 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/04/2006 | ||||||||
LastUpdateDate: | 08/11/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 2015-00681 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 4665893 | 05 | MI |   | MEDICAID | 1740382233 | 05 | VA |   | MEDICAID | 3714470 | 01 | TN | GROUP MEDICARE NUMBER | OTHER | 1506887 | 05 | TN |   | MEDICAID | 7100093950 | 05 | KY |   | MEDICAID |