Provider Demographics
NPI:1851389126
Name:KHATUA, SOUMEN (MD)
Entity Type:Individual
Prefix:DR
First Name:SOUMEN
Middle Name:
Last Name:KHATUA
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 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN68537208000000X, 2080P0207X
TXL57902080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100505379Medicaid
NV100505567Medicaid
100319Medicare ID - Type Unspecified
I25973Medicare UPIN