Provider Demographics
NPI:1780847137
Name:KANSAL, MAYANK M (MD)
Entity type:Individual
Prefix:DR
First Name:MAYANK
Middle Name:M
Last Name:KANSAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:840 S WOOD ST FL 9
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-996-9086
Mailing Address - Fax:312-413-1131
Practice Address - Street 1:840 S WOOD ST FL 9
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4325
Practice Address - Country:US
Practice Address - Phone:312-996-9086
Practice Address - Fax:312-413-1131
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115153207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ438352Medicaid
AZ438352Medicaid