Provider Demographics
NPI:1619900065
Name:KULSHRESTHA, PANKAJ (MD)
Entity Type:Individual
Prefix:
First Name:PANKAJ
Middle Name:
Last Name:KULSHRESTHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-1258
Mailing Address - Country:US
Mailing Address - Phone:917-536-6453
Mailing Address - Fax:
Practice Address - Street 1:3219 CENTRAL AVE STE 201
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-2903
Practice Address - Country:US
Practice Address - Phone:917-536-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE33767208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ016115Medicaid
AZZ179532Medicare PIN