Provider Demographics
NPI:1497700330
Name:KHOLWADWALA, SANJAY K (MD)
Entity type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:K
Last Name:KHOLWADWALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:10806 PINO AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-3432
Mailing Address - Country:US
Mailing Address - Phone:505-681-9131
Mailing Address - Fax:505-821-3773
Practice Address - Street 1:10501 GOLF COURSE RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5019
Practice Address - Country:US
Practice Address - Phone:505-727-2050
Practice Address - Fax:505-727-2049
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM97-288207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM66369Medicaid
NM66369Medicaid