Healthcare Provider Details

I. General information

NPI: 1043308760
Provider Name (Legal Business Name): KISHORCHANDRA R GONSAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 CAMPBELL AVE BULDING # 36
WEST HAVEN CT
06516-2770
US

IV. Provider business mailing address

44 COBBLESTONE DR
HAMDEN CT
06518-1749
US

V. Phone/Fax

Practice location:
  • Phone: 203-932-5711
  • Fax: 203-937-3478
Mailing address:
  • Phone: 203-248-7347
  • Fax: 203-248-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number036772
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number036772
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036772
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: