Provider Demographics
NPI:1093157877
Name:KHELA, GAGANPREET K (OD)
Entity Type:Individual
Prefix:MRS
First Name:GAGANPREET
Middle Name:K
Last Name:KHELA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:GANGANPRET
Other - Middle Name:
Other - Last Name:KAUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1960 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2206
Mailing Address - Country:US
Mailing Address - Phone:510-893-5566
Mailing Address - Fax:
Practice Address - Street 1:1960 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2206
Practice Address - Country:US
Practice Address - Phone:510-893-5566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14620152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA135970Medicaid