Provider Demographics
NPI:1801847736
Name:KHANJAR, SAMIR (MD)
Entity type:Individual
Prefix:
First Name:SAMIR
Middle Name:
Last Name:KHANJAR
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:401-444-6912
Practice Address - Street 1:11 FRIENDSHIP ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2209
Practice Address - Country:US
Practice Address - Phone:401-845-1652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD19955207V00000X
MDD0055137207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD603202800Medicaid
MDP00216349OtherMEDICARE RAILROAD
MDH02788Medicare UPIN
MD149L220ZMedicare ID - Type Unspecified
MD875M637FMedicare PIN