Provider Demographics
NPI:1861497372
Name:KHETAN, SHISHIR KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SHISHIR
Middle Name:KUMAR
Last Name:KHETAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 79632
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0632
Mailing Address - Country:US
Mailing Address - Phone:301-762-5020
Mailing Address - Fax:301-309-3783
Practice Address - Street 1:1201 SEVEN LOCKS RD
Practice Address - Street 2:STE 111
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20854-2957
Practice Address - Country:US
Practice Address - Phone:301-762-5020
Practice Address - Fax:301-294-7569
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME148198207R00000X
MDD0061630207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD416410500Medicaid
FLPENDINGOtherMEDICARE HF
DC189979Medicare PIN