Provider Demographics
NPI:1487782579
Name:KHANNA, KAMLESH (MD)
Entity type:Individual
Prefix:MRS
First Name:KAMLESH
Middle Name:
Last Name:KHANNA
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 1:401 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028
Mailing Address - Country:US
Mailing Address - Phone:973-748-6470
Mailing Address - Fax:973-748-1834
Practice Address - Street 1:401 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028
Practice Address - Country:US
Practice Address - Phone:973-748-6470
Practice Address - Fax:973-748-1834
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA27757208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
B17907Medicare UPIN