Provider Demographics
NPI:1902556277
Name:KHANDAVALLI, ANURAG (DO)
Entity Type:Individual
Prefix:
First Name:ANURAG
Middle Name:
Last Name:KHANDAVALLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36500 S GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-1772
Mailing Address - Country:US
Mailing Address - Phone:586-790-9003
Mailing Address - Fax:586-493-3603
Practice Address - Street 1:36500 S GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-1772
Practice Address - Country:US
Practice Address - Phone:586-790-9003
Practice Address - Fax:586-493-3603
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5151015492207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program