Provider Demographics
NPI:1649296104
Name:KHANDEKAR, SOFIA (MD)
Entity type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:KHANDEKAR
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 1:1251 WESLEY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-6442
Mailing Address - Country:US
Mailing Address - Phone:901-396-3061
Mailing Address - Fax:901-396-7841
Practice Address - Street 1:1251 WESLEY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6442
Practice Address - Country:US
Practice Address - Phone:901-396-3061
Practice Address - Fax:901-396-7841
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD010326207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3168542Medicaid
TN3168542Medicare ID - Type Unspecified
TNG07568Medicare UPIN