Provider Demographics
NPI:1205861614
Name:KANSAGRA MD, PRAVIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAVIN
Middle Name:J
Last Name:KANSAGRA MD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PRAVIN
Other - Middle Name:J
Other - Last Name:KANSAGRA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1092 S TAYLOR CT
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92808-2425
Mailing Address - Country:US
Mailing Address - Phone:714-335-8570
Mailing Address - Fax:714-280-0128
Practice Address - Street 1:1020 S ANAHEIM BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-5851
Practice Address - Country:US
Practice Address - Phone:714-335-8570
Practice Address - Fax:714-280-0128
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA4468502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4584291OtherAETNA
CA00A446850Medicaid
CA00A446850OtherBLUE CROSS
CA00A446850OtherBLUE SHIELD OF CA
CA00A446850OtherBLUE CROSS
CAE509741Medicare UPIN