Provider Demographics
NPI:1477557023
Name:KHEMSARA, VICKAS (MD)
Entity Type:Individual
Prefix:DR
First Name:VICKAS
Middle Name:
Last Name:KHEMSARA
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 1:1710 S HAWTHORNE RD
Mailing Address - Street 2:SUMMIT EYE CARE
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4016
Mailing Address - Country:US
Mailing Address - Phone:336-765-0960
Mailing Address - Fax:336-765-7453
Practice Address - Street 1:1710 SOUTH HAWTHORNE RD
Practice Address - Street 2:SUMMIT EYE CARE
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4016
Practice Address - Country:US
Practice Address - Phone:336-765-0960
Practice Address - Fax:336-765-7453
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01566207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
10584171OtherCAQH
NC01566OtherST LICENSE
NC5910540Medicaid
NC01566OtherST LICENSE
H39843Medicare UPIN