Provider Demographics
NPI:1376658948
Name:KHOZEMA RAJKOTWALA MD INC
Entity Type:Organization
Organization Name:KHOZEMA RAJKOTWALA MD INC
Other - Org Name:PRIMARY FAMILY HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD SELFEMPLOYED
Authorized Official - Prefix:DR
Authorized Official - First Name:KHOZEMA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAJKOTWALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-375-0775
Mailing Address - Street 1:990 SOUTH PROSPECT STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302
Mailing Address - Country:US
Mailing Address - Phone:740-375-0775
Mailing Address - Fax:740-375-0774
Practice Address - Street 1:990 SOUTH PROSPECT STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302
Practice Address - Country:US
Practice Address - Phone:740-375-0775
Practice Address - Fax:740-375-0774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350677778207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
110183567OtherRR MEDICARE
OH000000141025OtherANTHEM
OH0176321Medicaid
0404230OtherUHC
G12220Medicare UPIN
OH0176321Medicaid
OH6201090001Medicare NSC