Provider Demographics
NPI:1821069659
Name:KHANDELWAL, MANOJ (MD)
Entity Type:Individual
Prefix:
First Name:MANOJ
Middle Name:
Last Name:KHANDELWAL
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 1:362 SPRAGUE RD
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1124
Mailing Address - Country:US
Mailing Address - Phone:610-332-9207
Mailing Address - Fax:609-423-0306
Practice Address - Street 1:5735 RIDGE AVE STE 100A
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1746
Practice Address - Country:US
Practice Address - Phone:610-332-9207
Practice Address - Fax:609-423-0306
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD047445L207RI0011X
NJ25MA05176100207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6284809Medicaid
064295AFEMedicare PIN
B98069Medicare UPIN