Provider Demographics
NPI:1184930455
Name:KHATLANI, KHAULA (MD)
Entity type:Individual
Prefix:
First Name:KHAULA
Middle Name:
Last Name:KHATLANI
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 1:975 FARMINGTON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-3964
Mailing Address - Country:US
Mailing Address - Phone:860-589-0114
Mailing Address - Fax:860-589-1936
Practice Address - Street 1:975 FARMINGTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-3964
Practice Address - Country:US
Practice Address - Phone:860-589-0114
Practice Address - Fax:860-589-1936
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096855208600000X
CT57453390200000X
CT664712083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT66471OtherSTATE LICENSE