Healthcare Provider Details

I. General information

NPI: 1992741706
Provider Name (Legal Business Name): VIPUL R PANCHAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 DUTCHMANS PKWY SUITE 200
LOUISVILLE KY
40205-3372
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-891-8300
  • Fax: 502-891-8338
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number37828
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number37828
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: