Healthcare Provider Details

I. General information

NPI: 1467632521
Provider Name (Legal Business Name): VIMLA PRAVENI BHAGWANDIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 10/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6908 PROVIDENCE PARK DR S
MOBILE AL
36695-4600
US

IV. Provider business mailing address

6908 PROVIDENCE PARK DR S
MOBILE AL
36695-4600
US

V. Phone/Fax

Practice location:
  • Phone: 251-660-3490
  • Fax: 251-660-3491
Mailing address:
  • Phone: 251-660-3490
  • Fax: 251-660-3491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28261
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: