Provider Demographics
NPI:1063811859
Name:HAVASU CARDIAC SURGERY PLLC
Entity type:Organization
Organization Name:HAVASU CARDIAC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PANKAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:KULSHRESTHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-536-6453
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-0707
Mailing Address - Country:US
Mailing Address - Phone:917-536-6453
Mailing Address - Fax:888-491-7482
Practice Address - Street 1:1741 MESQUITE AVE
Practice Address - Street 2:STE. A200
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5695
Practice Address - Country:US
Practice Address - Phone:917-536-6453
Practice Address - Fax:888-491-7482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36397208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP-1944708-5OtherCORPORATION NUMBER
AZ016115Medicaid
AZZ179533Medicare PIN