Provider Demographics
NPI:1427038371
Name:KHETIA, ERIC A (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:A
Last Name:KHETIA
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 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4919
Mailing Address - Country:US
Mailing Address - Phone:651-968-5042
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:1185 TOWN CENTRE DR STE 100
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1188
Practice Address - Country:US
Practice Address - Phone:651-968-5230
Practice Address - Fax:651-994-3982
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49168207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00340061OtherRAILROAD MEDICARE
MN200002482Medicare PIN
I35737Medicare UPIN