Provider Demographics
NPI:1669992160
Name:KHATIWALA, SONYA (MD)
Entity type:Individual
Prefix:DR
First Name:SONYA
Middle Name:
Last Name:KHATIWALA
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 1:257 SHUTE HARBOUR RD
Mailing Address - Street 2:
Mailing Address - City:AIRLIE BEACH
Mailing Address - State:QUEENSLAND
Mailing Address - Zip Code:04802
Mailing Address - Country:AU
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:257 SHUTE HARBOUR RD
Practice Address - Street 2:
Practice Address - City:AIRLIE BEACH
Practice Address - State:QUEENSLAND
Practice Address - Zip Code:04802
Practice Address - Country:AU
Practice Address - Phone:074-946-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine