Provider Demographics
NPI:1700841350
Name:KUMAR, PREM C (MD)
Entity Type:Individual
Prefix:DR
First Name:PREM
Middle Name:C
Last Name:KUMAR
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 1:215 S POWER RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-5235
Mailing Address - Country:US
Mailing Address - Phone:480-985-9005
Mailing Address - Fax:480-396-9974
Practice Address - Street 1:215 S POWER RD
Practice Address - Street 2:102
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-985-9005
Practice Address - Fax:480-649-3685
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12854207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0002430OtherBCBS
AZ215104Medicaid
D37155Medicare UPIN
AZZ72609Medicare PIN