Provider Demographics
NPI:1275771503
Name:KHANNA PEDIATRICS, LLC
Entity Type:Organization
Organization Name:KHANNA PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANNA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-748-6470
Mailing Address - Street 1:401 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-1512
Mailing Address - Country:US
Mailing Address - Phone:973-748-6470
Mailing Address - Fax:973-748-1834
Practice Address - Street 1:401 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028-1512
Practice Address - Country:US
Practice Address - Phone:973-748-6470
Practice Address - Fax:973-748-1834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08137900208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0182796Medicaid