Provider Demographics
NPI:1174044176
Name:KHANAL, BISHAL (MD)
Entity Type:Individual
Prefix:
First Name:BISHAL
Middle Name:
Last Name:KHANAL
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 1:11 ANTHONY RD APT I
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-2455
Mailing Address - Country:US
Mailing Address - Phone:330-565-7277
Mailing Address - Fax:
Practice Address - Street 1:500 GYPSY LANE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44501
Practice Address - Country:US
Practice Address - Phone:330-884-4250
Practice Address - Fax:330-884-0651
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2020-10-27
Deactivation Date:2018-02-01
Deactivation Code:
Reactivation Date:2018-03-13
Provider Licenses
StateLicense IDTaxonomies
CT1.066769207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine