Provider Demographics
NPI:1033289129
Name:KANSAL, J K (MD, PC)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:K
Last Name:KANSAL
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8969 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7039
Mailing Address - Country:US
Mailing Address - Phone:219-769-7761
Mailing Address - Fax:219-769-0895
Practice Address - Street 1:8969 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7039
Practice Address - Country:US
Practice Address - Phone:219-769-7761
Practice Address - Fax:219-769-0895
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50005027174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INB29111Medicare UPIN