Provider Demographics
NPI:1013023423
Name:KHEDKAR, MONA (MD)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:
Last Name:KHEDKAR
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 1:410 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1635
Mailing Address - Country:US
Mailing Address - Phone:973-661-0006
Mailing Address - Fax:973-661-4473
Practice Address - Street 1:410 CENTRE ST
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-1635
Practice Address - Country:US
Practice Address - Phone:973-661-0006
Practice Address - Fax:973-661-4473
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA035867002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE54393Medicare UPIN
NJ563325MGKMedicare ID - Type Unspecified