Provider Demographics
NPI:1689987521
Name:PRAVIN J KANSAGRA MD INC
Entity Type:Organization
Organization Name:PRAVIN J KANSAGRA MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRAVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KANSAGRA, MD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-335-8570
Mailing Address - Street 1:1092 S TAYLOR CT
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92808-2425
Mailing Address - Country:US
Mailing Address - Phone:714-335-8570
Mailing Address - Fax:714-280-0128
Practice Address - Street 1:1020 S ANAHEIM BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-5851
Practice Address - Country:US
Practice Address - Phone:714-335-8570
Practice Address - Fax:714-280-0128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44685261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A446850Medicaid
4584291OtherAETNA
CA546651409OtherPACIFICARE
CA546651409 02OtherPACIFICARE BEHAVIORAL HEALTH
CA22139OtherWINDSTONE
284863OtherVALUEOPTIONS
CA1021522OtherCIGNA
796687000OtherMAGELLAN
CA00A446850OtherBLUE SHIELD
CA00A446850OtherBLUE CROSS
060111OtherMANAGED HEALTH NETWORK
CA00A446850OtherBLUE CROSS