Provider Demographics
NPI:1134143134
Name:KHETAN, ROGER S (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:S
Last Name:KHETAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 JUNIUS ST STE 415
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1617
Mailing Address - Country:US
Mailing Address - Phone:972-993-8300
Mailing Address - Fax:972-993-8301
Practice Address - Street 1:3900 JUNIUS ST STE 415
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1617
Practice Address - Country:US
Practice Address - Phone:972-993-8300
Practice Address - Fax:972-993-8301
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4105207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101839201Medicaid
TX101839203Medicaid
TX84421XOtherBCBS
TX101839204Medicaid
TX8CZ696OtherBCBSTX
TX110185918Medicare PIN
TX8CZ696OtherBCBSTX
TXTXB132516Medicare PIN
TX101839201Medicaid
TX8L26142Medicare PIN