Provider Demographics
NPI:1699734038
Name:KHANDELWAL, VIVEK (MD)
Entity type:Individual
Prefix:DR
First Name:VIVEK
Middle Name:
Last Name:KHANDELWAL
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 1:970 E WASHINGTON ST
Mailing Address - Street 2:SUITE #2F
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2181
Mailing Address - Country:US
Mailing Address - Phone:330-723-7999
Mailing Address - Fax:330-764-9907
Practice Address - Street 1:970 E WASHINGTON ST
Practice Address - Street 2:SUITE #2F
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2181
Practice Address - Country:US
Practice Address - Phone:330-723-7999
Practice Address - Fax:330-764-9907
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427120207R00000X
OH35-094324207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4273911OtherMEDICARE PTAN
PA101382073Medicaid
OH4273911OtherMEDICARE PTAN
I39886Medicare UPIN