Provider Demographics
NPI:1295996916
Name:KHANDAVALLI, SARAT CHANDRA (MD)
Entity type:Individual
Prefix:
First Name:SARAT
Middle Name:CHANDRA
Last Name:KHANDAVALLI
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 1629
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-1629
Mailing Address - Country:US
Mailing Address - Phone:877-378-4293
Mailing Address - Fax:419-223-2726
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9606
Practice Address - Country:US
Practice Address - Phone:616-252-7166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097445207ZP0102X
NY250548207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11295996916Medicaid