Provider Demographics
NPI:1609213636
Name:KHATIWODA, ARYA (DO)
Entity Type:Individual
Prefix:
First Name:ARYA
Middle Name:
Last Name:KHATIWODA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD
Mailing Address - Street 2:# A109F
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:2900 HANNAH BLVD STE 104
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5380
Practice Address - Country:US
Practice Address - Phone:517-364-8118
Practice Address - Fax:517-364-8119
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101020314208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology