Provider Demographics
NPI:1285667295
Name:KHETIA, PREMAL (MD)
Entity type:Individual
Prefix:
First Name:PREMAL
Middle Name:
Last Name:KHETIA
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 1:1145 S UTICA AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4000
Mailing Address - Country:US
Mailing Address - Phone:918-579-3825
Mailing Address - Fax:918-579-1262
Practice Address - Street 1:1023 E CHERRY ST
Practice Address - Street 2:SUITE B
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-4105
Practice Address - Country:US
Practice Address - Phone:918-225-1165
Practice Address - Fax:918-225-1953
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK23518207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F83078Medicare UPIN