Healthcare Provider Details

I. General information

NPI: 1669499331
Provider Name (Legal Business Name): ANAND G KANTAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 32ND AVE S
FARGO ND
58103-5800
US

IV. Provider business mailing address

2400 32ND AVE S
FARGO ND
58103-5800
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-8800
  • Fax:
Mailing address:
  • Phone: 701-234-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number5636
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: