Provider Demographics
NPI:1982687828
Name:KHALSA, SIRI CHAND K (MD)
Entity Type:Individual
Prefix:
First Name:SIRI CHAND
Middle Name:K
Last Name:KHALSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W CLARENDON AVE
Mailing Address - Street 2:B13
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3413
Mailing Address - Country:US
Mailing Address - Phone:480-747-3083
Mailing Address - Fax:
Practice Address - Street 1:320 W PRINCE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-3526
Practice Address - Country:US
Practice Address - Phone:520-679-3909
Practice Address - Fax:520-388-7170
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34227207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ973843Medicaid
AZ105799Medicare ID - Type Unspecified
AZ973843Medicaid