Healthcare Provider Details

I. General information

NPI: 1033289129
Provider Name (Legal Business Name): J K KANSAL M.D., P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 02/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8969 BROADWAY
MERRILLVILLE IN
46410-7039
US

IV. Provider business mailing address

8969 BROADWAY
MERRILLVILLE IN
46410-7039
US

V. Phone/Fax

Practice location:
  • Phone: 219-769-7761
  • Fax: 219-769-0895
Mailing address:
  • Phone: 219-769-7761
  • Fax: 219-769-0895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number50005027
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: