Provider Demographics
NPI:1609839331
Name:KANSAGRA, KETAN
Entity Type:Individual
Prefix:DR
First Name:KETAN
Middle Name:
Last Name:KANSAGRA
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 1:16 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-8570
Mailing Address - Country:US
Mailing Address - Phone:732-951-9692
Mailing Address - Fax:
Practice Address - Street 1:254 EASTON AVE
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1766
Practice Address - Country:US
Practice Address - Phone:732-745-8600
Practice Address - Fax:732-249-9572
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA761662080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0006670Medicaid