Provider Demographics
NPI:1164919783
Name:KHANNA, DEEPAK (DO)
Entity Type:Individual
Prefix:MR
First Name:DEEPAK
Middle Name:
Last Name:KHANNA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LIPNICK LN
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1955
Mailing Address - Country:US
Mailing Address - Phone:732-343-5242
Mailing Address - Fax:
Practice Address - Street 1:501 S 54TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1900
Practice Address - Country:US
Practice Address - Phone:215-748-9707
Practice Address - Fax:215-748-9708
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS021567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program