=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386694586
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KASHYAP BHARAT KANSUPADA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 04/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 PARK ST
-----------------------------------------------------
City | BELMONT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28012-3368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-295-3700
-----------------------------------------------------
Fax | 704-295-3707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6035 FAIRVIEW RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-3256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-295-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 9600585
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------