Provider Demographics
NPI:1659301844
Name:PRAKASH K KHANDEKAR MD
Entity Type:Organization
Organization Name:PRAKASH K KHANDEKAR MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAKASH
Authorized Official - Middle Name:K
Authorized Official - Last Name:KHANDEKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-442-3334
Mailing Address - Street 1:6803 MAYFIELD RD
Mailing Address - Street 2:310
Mailing Address - City:MAYFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2215
Mailing Address - Country:US
Mailing Address - Phone:440-442-3334
Mailing Address - Fax:440-442-4948
Practice Address - Street 1:6803 MAYFIELD RD
Practice Address - Street 2:310
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2215
Practice Address - Country:US
Practice Address - Phone:440-442-3334
Practice Address - Fax:440-442-4948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.033148207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0179640Medicaid
OH0179640Medicaid
OH0179640Medicaid
A73689Medicare UPIN