1972709269 NPI number — DR. KAVITA VIJAYAM KANTAK M.D.

Table of content: DR. KAVITA VIJAYAM KANTAK M.D. (NPI 1972709269)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972709269 NPI number — DR. KAVITA VIJAYAM KANTAK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KANTAK
Provider First Name:
KAVITA
Provider Middle Name:
VIJAYAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TANGUTURI
Provider Other First Name:
KAVITA
Provider Other Middle Name:
VIJAYAM
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972709269
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 SPRING FOREST RD
Provider Second Line Business Mailing Address:
STE 130
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27616-2880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-882-0706
Provider Business Mailing Address Fax Number:
919-873-9821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 ERWIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27705-3941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-684-8111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  2011-00578 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)