1689987521 NPI number — PRAVIN J KANSAGRA MD INC

Table of content: (NPI 1689987521)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689987521 NPI number — PRAVIN J KANSAGRA MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAVIN J KANSAGRA MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689987521
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1092 S TAYLOR CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANAHEIM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92808-2425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-335-8570
Provider Business Mailing Address Fax Number:
714-280-0128

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1020 S ANAHEIM BLVD
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
ANAHEIM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92805-5851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-335-8570
Provider Business Practice Location Address Fax Number:
714-280-0128
Provider Enumeration Date:
07/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KANSAGRA, MD
Authorized Official First Name:
PRAVIN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
714-335-8570

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  A44685 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00A446850 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4584291 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 546651409 . This is a "PACIFICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 546651409 02 . This is a "PACIFICARE BEHAVIORAL HEALTH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 22139 . This is a "WINDSTONE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 284863 . This is a "VALUEOPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1021522 . This is a "CIGNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 796687000 . This is a "MAGELLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00A446850 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A446850 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 060111 . This is a "MANAGED HEALTH NETWORK" identifier . This identifiers is of the category "OTHER".




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