Provider Demographics
NPI:1447580881
Name:KAUSHALYA BENIWAL M D S C
Entity Type:Organization
Organization Name:KAUSHALYA BENIWAL M D S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAUSHALYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENIWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-282-1961
Mailing Address - Street 1:2745 W LAYTON AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2651
Mailing Address - Country:US
Mailing Address - Phone:414-282-1961
Mailing Address - Fax:
Practice Address - Street 1:2745 W LAYTON AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-2651
Practice Address - Country:US
Practice Address - Phone:414-282-1961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25201207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30621400Medicaid