Provider Demographics
NPI:1740382233
Name:KHANNA, ATUL (MD)
Entity Type:Individual
Prefix:
First Name:ATUL
Middle Name:
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 1:13808 PROFESSIONAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7948
Mailing Address - Country:US
Mailing Address - Phone:704-377-4009
Mailing Address - Fax:423-431-1811
Practice Address - Street 1:2015 RANDOLPH ROAD
Practice Address - Street 2:SUITE 208
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1200
Practice Address - Country:US
Practice Address - Phone:704-377-4009
Practice Address - Fax:423-431-1811
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00681207RG0100X
TNMD43820207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4665893Medicaid
VA1740382233Medicaid
TN3714470OtherGROUP MEDICARE NUMBER
TN1506887Medicaid
KY7100093950Medicaid
I22650Medicare UPIN
KY7100093950Medicaid
TN3714470OtherGROUP MEDICARE NUMBER