Provider Demographics
NPI:1083609622
Name:KHANDELWAL, SHOBHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOBHA
Middle Name:
Last Name:KHANDELWAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHOBHA
Other - Middle Name:KUMARI
Other - Last Name:MOHANKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MBBS
Mailing Address - Street 1:970 E WASHINGTON ST
Mailing Address - Street 2:STE 2F
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2181
Mailing Address - Country:US
Mailing Address - Phone:330-722-8886
Mailing Address - Fax:330-764-9907
Practice Address - Street 1:970 E WASHINGTON ST
Practice Address - Street 2:STE-2F
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3332
Practice Address - Country:US
Practice Address - Phone:330-723-7999
Practice Address - Fax:330-764-9907
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH054767K207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0788750Medicaid
OH0788750Medicaid
E54688Medicare UPIN