Healthcare Provider Details

I. General information

NPI: 1245585280
Provider Name (Legal Business Name): VAISHALI KHETARPAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 03/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 N 51ST AVE
PHOENIX AZ
85031-2601
US

IV. Provider business mailing address

4011 N 51ST AVE
PHOENIX AZ
85031-2601
US

V. Phone/Fax

Practice location:
  • Phone: 623-344-6900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5315060606
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.127215
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier118512400
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: