Provider Demographics
NPI:1043364656
Name:KHULLAR, SANJIV K (MD)
Entity type:Individual
Prefix:DR
First Name:SANJIV
Middle Name:K
Last Name:KHULLAR
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 1:2726 FULTON DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3506
Mailing Address - Country:US
Mailing Address - Phone:330-455-5011
Mailing Address - Fax:330-588-7127
Practice Address - Street 1:2726 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3506
Practice Address - Country:US
Practice Address - Phone:330-455-5011
Practice Address - Fax:330-588-7127
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076082207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2217260OtherAETNA
100238OtherKAISER
OH2177960Medicaid
0400049OtherUNITED HEALTHCARE
100013229OtherRAILROAD MEDICARE
000000126859OtherANTHEM
000000126859OtherANTHEM
0400049OtherUNITED HEALTHCARE
OH2177960Medicaid