Provider Demographics
NPI:1497591044
Name:GHODASARA, KISHAN KETAN (MD)
Entity type:Individual
Prefix:DR
First Name:KISHAN
Middle Name:KETAN
Last Name:GHODASARA
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 1:312 REGENCY DR
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-1618
Mailing Address - Country:US
Mailing Address - Phone:215-237-2979
Mailing Address - Fax:
Practice Address - Street 1:420 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-2143
Practice Address - Country:US
Practice Address - Phone:484-628-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT231734207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty