Provider Demographics
NPI:1689844813
Name:KAWANKAR, SANJAY SURESH
Entity type:Individual
Prefix:
First Name:SANJAY
Middle Name:SURESH
Last Name:KAWANKAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 W BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2309
Mailing Address - Country:US
Mailing Address - Phone:323-727-2887
Mailing Address - Fax:323-727-2854
Practice Address - Street 1:2625 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2309
Practice Address - Country:US
Practice Address - Phone:323-727-2887
Practice Address - Fax:323-727-2854
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC22146222Z00000X
DECP0034041744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist