Provider Demographics
NPI:1063605293
Name:KHIANI, SANJAY J (MD)
Entity type:Individual
Prefix:
First Name:SANJAY
Middle Name:J
Last Name:KHIANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10370 PARK RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8508
Mailing Address - Country:US
Mailing Address - Phone:704-817-2022
Mailing Address - Fax:704-817-2024
Practice Address - Street 1:10370 PARK RD
Practice Address - Street 2:SUITE 202
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8508
Practice Address - Country:US
Practice Address - Phone:704-817-2022
Practice Address - Fax:704-817-2024
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51918207K00000X
KY41230207K00000X
NC2012-00056207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35337600Medicaid
IN200874570Medicaid
IN200340800Medicaid
KY000000541483OtherANTHEM PIN
KY9454082OtherAETNA PIN
KY000000541483OtherANTHEM PIN
IN200340800Medicaid