Provider Demographics
NPI:1437155678
Name:KANTH, PRAVEENA M (MD)
Entity Type:Individual
Prefix:
First Name:PRAVEENA
Middle Name:M
Last Name:KANTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:6545 FRANCE AVE S
Mailing Address - Street 2:SUITE 150
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2131
Mailing Address - Country:US
Mailing Address - Phone:952-848-5600
Mailing Address - Fax:952-848-5573
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:SUITE 150
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:952-848-5600
Practice Address - Fax:952-848-5573
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2012-03-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN36578207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN337025900Medicaid
F67279Medicare UPIN
MN11009206Medicare ID - Type Unspecified