Provider Demographics
NPI:1003924259
Name:KHATIWALA, MANISHA (MD)
Entity Type:Individual
Prefix:
First Name:MANISHA
Middle Name:
Last Name:KHATIWALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6896 W SNOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-3214
Mailing Address - Country:US
Mailing Address - Phone:440-717-6600
Mailing Address - Fax:
Practice Address - Street 1:1925 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-6713
Practice Address - Country:US
Practice Address - Phone:609-345-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07978300207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0096181Medicaid
NJ2645115000OtherAMRRIHEALTH
NJ30035356OtherKEYSTONE MERCY
NJ60021304OtherHORIZON NJ HEALTH
NJBK8531594OtherDEA
NJH20416Medicare UPIN
NJBK8531594OtherDEA
NJ2645115000OtherAMRRIHEALTH
NJ105884ZEDBMedicare PIN