Provider Demographics
NPI:1396866216
Name:KANSAL, PREM K
Entity Type:Individual
Prefix:
First Name:PREM
Middle Name:K
Last Name:KANSAL
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 1:445 WINN WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1707
Mailing Address - Country:US
Mailing Address - Phone:404-294-3745
Mailing Address - Fax:
Practice Address - Street 1:400 FOREST AVENEUE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213
Practice Address - Country:US
Practice Address - Phone:718-221-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA234632084P0800X
NY1565992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY156599Medicaid
NYF05607Medicare UPIN