Provider Demographics
NPI:1083770184
Name:VADSOLA, KANTILAL
Entity Type:Individual
Prefix:MR
First Name:KANTILAL
Middle Name:
Last Name:VADSOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3024
Mailing Address - Country:US
Mailing Address - Phone:516-599-0079
Mailing Address - Fax:516-599-0099
Practice Address - Street 1:18 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3024
Practice Address - Country:US
Practice Address - Phone:516-599-0079
Practice Address - Fax:516-599-0099
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01106692Medicaid
NY01106692Medicaid