Healthcare Provider Details

I. General information

NPI: 1992799530
Provider Name (Legal Business Name): PRAVIN M PANCHAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 10/18/2020
Certification Date: 10/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9670 MAGNOLIA AVE STE 201
RIVERSIDE CA
92503-3684
US

IV. Provider business mailing address

9670 MAGNOLIA AVE STE 201
RIVERSIDE CA
92503-3684
US

V. Phone/Fax

Practice location:
  • Phone: 951-333-3662
  • Fax: 951-352-3161
Mailing address:
  • Phone: 951-352-7400
  • Fax: 951-352-3161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA066826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: