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General NPI Number Information
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NPI Number | 1063811859
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Entity Type | Organization
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Legal Business Name | HAVASU CARDIAC SURGERY PLLC
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Dates
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Enumeration Date | 08/18/2014
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Last Update Date | 02/22/2017
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Provider Practice Location Address
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Address Line | 1741 MESQUITE AVE STE. A200
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5695
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Country | US
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Telephone | 917-536-6453
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Fax | 888-491-7482
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Provider Business Mailing Address
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Address Line | PO BOX 707
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86405-0707
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Country | US
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Telephone | 917-536-6453
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Fax | 888-491-7482
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | PANKAJ KULSHRESTHA
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Credential | M.D.
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Telephone | 917-536-6453
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208G00000X
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Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
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License Number | 36397
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License Number State | AZ
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