Provider Demographics
NPI:1043277395
Name:KHANDERIA, SHAMOLI (DO)
Entity Type:Individual
Prefix:
First Name:SHAMOLI
Middle Name:
Last Name:KHANDERIA
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 1:207 FLETCHER ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-1050
Mailing Address - Country:US
Mailing Address - Phone:734-764-8320
Mailing Address - Fax:734-763-7505
Practice Address - Street 1:207 FLETCHER ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1050
Practice Address - Country:US
Practice Address - Phone:734-764-8320
Practice Address - Fax:734-763-7505
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018559207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200871670Medicaid
INP00471980OtherMEDICARE - RAILROAD
IN200871670Medicaid
IL144503Medicare UPIN