Provider Demographics
NPI:1487848735
Name:KHANNA, SHYAM LAL (MD)
Entity Type:Individual
Prefix:DR
First Name:SHYAM
Middle Name:LAL
Last Name:KHANNA
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 1:32220 SCENIC LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025-1037
Mailing Address - Country:US
Mailing Address - Phone:313-533-1300
Mailing Address - Fax:313-533-1301
Practice Address - Street 1:24621 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3670
Practice Address - Country:US
Practice Address - Phone:313-533-1300
Practice Address - Fax:313-533-1301
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISK045240207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3288873Medicaid
MI0820228Medicare PIN
B44838Medicare UPIN