Provider Demographics
NPI:1619186228
Name:KHANDELWAL, NIRAJ (MD, MHS)
Entity Type:Individual
Prefix:
First Name:NIRAJ
Middle Name:
Last Name:KHANDELWAL
Suffix:
Gender:M
Credentials:MD, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 COLLIER RD NW
Mailing Address - Street 2:SUITE 4075
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1796
Mailing Address - Country:US
Mailing Address - Phone:404-355-3200
Mailing Address - Fax:404-355-9316
Practice Address - Street 1:1265 HIGHWAY 54 W
Practice Address - Street 2:SUITE 402
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4548
Practice Address - Country:US
Practice Address - Phone:770-719-3240
Practice Address - Fax:770-719-3241
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH57.017193207RG0100X
GA67781207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP1-0022713OtherINSTITUTIONAL PERMIT