Provider Demographics
NPI:1104189190
Name:KHANNA, NIDHI (DO)
Entity Type:Individual
Prefix:DR
First Name:NIDHI
Middle Name:
Last Name:KHANNA
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 1:11 UPPER RIVERDALE RD SW
Mailing Address - Street 2:SUITE 10
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 UPPER RIVERDALE RD SW STE 10
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2615
Practice Address - Country:US
Practice Address - Phone:770-991-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-24
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA78777208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty