Provider Demographics
NPI:1033506258
Name:KHETTRY, ANUJA (MD)
Entity Type:Individual
Prefix:
First Name:ANUJA
Middle Name:
Last Name:KHETTRY
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 1:2020 CENTRE STREET
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02132
Mailing Address - Country:US
Mailing Address - Phone:617-522-3100
Mailing Address - Fax:617-522-6366
Practice Address - Street 1:2020 CENTRE STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02132
Practice Address - Country:US
Practice Address - Phone:617-522-3100
Practice Address - Fax:617-522-6366
Is Sole Proprietor?:No
Enumeration Date:2015-04-26
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA275240208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110160017AMedicaid