Provider Demographics
NPI:1871595942
Name:KHANDELWAL, MUKUL (MD)
Entity type:Individual
Prefix:DR
First Name:MUKUL
Middle Name:
Last Name:KHANDELWAL
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 1:502 PINEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-2320
Mailing Address - Country:US
Mailing Address - Phone:410-590-8920
Mailing Address - Fax:410-553-2345
Practice Address - Street 1:8109 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-6917
Practice Address - Country:US
Practice Address - Phone:410-590-8920
Practice Address - Fax:410-553-2345
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052387207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD369600600Medicaid
F85295Medicare UPIN