Healthcare Provider Details

I. General information

NPI: 1275856403
Provider Name (Legal Business Name): HEENA DEEPAK PANCHAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5755 COTTLE RD
SAN JOSE CA
95123-3640
US

IV. Provider business mailing address

5755 COTTLE RD
SAN JOSE CA
95123-3640
US

V. Phone/Fax

Practice location:
  • Phone: 408-972-3095
  • Fax:
Mailing address:
  • Phone: 412-624-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number144576
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number144576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: