Provider Demographics
NPI:1639223308
Name:KHETARPAL, SANJIV (MD)
Entity Type:Individual
Prefix:
First Name:SANJIV
Middle Name:
Last Name:KHETARPAL
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:PO BOX 36329
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44735
Mailing Address - Country:US
Mailing Address - Phone:330-493-1480
Mailing Address - Fax:330-493-6805
Practice Address - Street 1:4665 BELPAR ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718
Practice Address - Country:US
Practice Address - Phone:330-493-1480
Practice Address - Fax:330-493-6805
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063232207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0904758Medicaid
2217260OtherAETNA
000000126856OtherANTHEM
100005648OtherRAILROAD MEDICARE
100235OtherKAISER
87738OtherQUAL CHOICE
2900159OtherUNITED HEALTHCARE
E05026Medicare UPIN
OH0904758Medicaid