Basic Information
| Provider Information | |||||||||
| NPI: | 1770756587 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | KHANNIA | ||||||||
| MiddleName: | ERIF | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347873546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 3527423264 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TAVARES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327783808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 3527423264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2008 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2011024868 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME123627 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 014797300 | 05 | FL | MEDICAID |