Provider Demographics
NPI:1801865464
Name:KANCHWALA, KHUZEMA (MD)
Entity Type:Individual
Prefix:
First Name:KHUZEMA
Middle Name:
Last Name:KANCHWALA
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 1:1068 W BALTIMORE PIKE
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063
Mailing Address - Country:US
Mailing Address - Phone:610-627-4216
Mailing Address - Fax:610-627-4230
Practice Address - Street 1:1068 W BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063
Practice Address - Country:US
Practice Address - Phone:610-627-4216
Practice Address - Fax:610-627-4230
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037264E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
E73834Medicare UPIN
PA482430Medicare ID - Type Unspecified