Basic Information
| Provider Information | |||||||||
| NPI: | 1659323319 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ATHAVALE | ||||||||
| FirstName: | KAMLESH | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5213 S ALSTON AVE | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277134430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196848111 | ||||||||
| FaxNumber: | 9196204921 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 ERWIN RD | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277053941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196848111 | ||||||||
| FaxNumber: | 9196204921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 05/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 2006-01493 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32197 | 01 | FL | BCBS | OTHER | 272119800 | 05 | FL | MEDICAID |