Provider Demographics
NPI:1700895380
Name:KANSUPADA, AMEESHA PANDYA (MD)
Entity Type:Individual
Prefix:
First Name:AMEESHA
Middle Name:PANDYA
Last Name:KANSUPADA
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 1:2001 VAIL AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6115 PARK SOUTH DR STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3281
Practice Address - Country:US
Practice Address - Phone:704-554-8787
Practice Address - Fax:704-554-8774
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600964207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8947723Medicaid
NC1700895380Medicaid
SCN00964Medicaid
NCG32242Medicare UPIN
NCNCA759DMedicare PIN
NC8947723Medicaid