Healthcare Provider Details

I. General information

NPI: 1912172149
Provider Name (Legal Business Name): PUSHPJEET SINGH KANWAR M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 N 3RD ST
MACCLENNY FL
32063-2103
US

IV. Provider business mailing address

159 N 3RD ST
MACCLENNY FL
32063-2103
US

V. Phone/Fax

Practice location:
  • Phone: 904-259-3151
  • Fax:
Mailing address:
  • Phone: 904-259-3151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD0083533
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME149153
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: