Provider Demographics
NPI:1942281654
Name:PANESAR, KELVIN S (MD)
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:S
Last Name:PANESAR
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:PO BOX 9362
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9362
Mailing Address - Country:US
Mailing Address - Phone:480-892-2260
Mailing Address - Fax:480-892-2274
Practice Address - Street 1:10250 N 92ND ST
Practice Address - Street 2:308
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4510
Practice Address - Country:US
Practice Address - Phone:480-892-2260
Practice Address - Fax:480-892-2274
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ264152080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ429325Medicaid
AZ429325Medicaid
I09418Medicare UPIN