Provider Demographics
NPI:1265462139
Name:KHETAN, SURESH K (MD)
Entity Type:Individual
Prefix:MR
First Name:SURESH
Middle Name:K
Last Name:KHETAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 7398
Mailing Address - Street 2:
Mailing Address - City:LANGLEY PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20787-7398
Mailing Address - Country:US
Mailing Address - Phone:301-963-3456
Mailing Address - Fax:301-963-0424
Practice Address - Street 1:7610 CARROLL AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912
Practice Address - Country:US
Practice Address - Phone:301-891-9770
Practice Address - Fax:301-891-1620
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD55403207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H14610Medicare UPIN
MD00A585S69Medicare PIN