Provider Demographics
NPI:1861506669
Name:KHANDHERIA, MANOJ P (MD)
Entity Type:Individual
Prefix:
First Name:MANOJ
Middle Name:P
Last Name:KHANDHERIA
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:PO BOX 64056
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79464-4056
Mailing Address - Country:US
Mailing Address - Phone:806-795-2533
Mailing Address - Fax:806-795-0336
Practice Address - Street 1:2424 50TH ST RM 301
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79412-2561
Practice Address - Country:US
Practice Address - Phone:806-795-2533
Practice Address - Fax:806-795-0336
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4324208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097789402Medicaid
TXB23927Medicare UPIN
00CU84Medicare ID - Type Unspecified