Provider Demographics
NPI:1851328850
Name:PEMA, KANCHAN M (MD)
Entity Type:Individual
Prefix:
First Name:KANCHAN
Middle Name:M
Last Name:PEMA
Suffix:
Gender:F
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:PO BOX 9520
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79995-9520
Mailing Address - Country:US
Mailing Address - Phone:915-545-9795
Mailing Address - Fax:915-545-9799
Practice Address - Street 1:4801 ALBERTA AVE.
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905
Practice Address - Country:US
Practice Address - Phone:915-545-6647
Practice Address - Fax:915-545-9799
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0719207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX106219201Medicaid
TX89C116Medicare ID - Type Unspecified
TX106219201Medicaid