Basic Information
| Provider Information | |||||||||
| NPI: | 1295839900 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VA-CT HEALTHCARE SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OPIOID TREATMENT PROGRAM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 950 CAMPBELL AVE | ||||||||
| Address2: | BULD# 36, MAIL CODE 116 A4 | ||||||||
| City: | WEST HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065162770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039325711 | ||||||||
| FaxNumber: | 2039373478 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 CAMPBELL AVE | ||||||||
| Address2: | BULD# 36, MAIL CODE 116 A4 | ||||||||
| City: | WEST HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065162770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039325711 | ||||||||
| FaxNumber: | 2039373478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GONSAI | ||||||||
| AuthorizedOfficialFirstName: | KISHORCHANDRA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/PSYCHATRYMEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2039325711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 036772 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 036772 | 01 | CT | PHYSICIAN | OTHER |