Provider Demographics
NPI:1831160589
Name:KHATIWALA, VIJAY (MD)
Entity type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:
Last Name:KHATIWALA
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 1:640 E 233RD ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-2802
Mailing Address - Country:US
Mailing Address - Phone:718-325-3500
Mailing Address - Fax:718-325-4655
Practice Address - Street 1:640 E 233RD ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-2802
Practice Address - Country:US
Practice Address - Phone:718-325-3500
Practice Address - Fax:718-325-4655
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193352207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01424051Medicaid
NY01424051Medicaid
NY97H102Medicare PIN
990012691Medicare PIN