Basic Information
| Provider Information | |||||||||
| NPI: | 1144278805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANSAL | ||||||||
| FirstName: | NIKHIL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 200 W ARBOR DR | ||||||||
| Address2: | MC 8403 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921038403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195436980 | ||||||||
| FaxNumber: | 6195432615 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 W ARBOR DR | ||||||||
| Address2: | MC 8201 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921038201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195431899 | ||||||||
| FaxNumber: | 6195433183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A73784 | CA | X | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | A73784 | CA | X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00A737840 | 05 | CA | MEDICAID |