Provider Demographics
NPI:1972709269
Name:KANTAK, KAVITA VIJAYAM (MD)
Entity type:Individual
Prefix:DR
First Name:KAVITA
Middle Name:VIJAYAM
Last Name:KANTAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KAVITA
Other - Middle Name:VIJAYAM
Other - Last Name:TANGUTURI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3100 SPRING FOREST RD
Mailing Address - Street 2:STE 130
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:919-882-0706
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:2100 ERWIN RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3941
Practice Address - Country:US
Practice Address - Phone:919-684-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-00578207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program