Provider Demographics
NPI:1528452539
Name:KHOLWADWALA, PRIYA DIPAK (DO)
Entity type:Individual
Prefix:
First Name:PRIYA
Middle Name:DIPAK
Last Name:KHOLWADWALA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BALSAM DR
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-2004
Mailing Address - Country:US
Mailing Address - Phone:516-244-3349
Mailing Address - Fax:
Practice Address - Street 1:210-31 26TH AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-1949
Practice Address - Country:US
Practice Address - Phone:718-747-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY28576301208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics