Healthcare Provider Details

I. General information

NPI: 1720391493
Provider Name (Legal Business Name): SHRUTI VAKIL M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2010
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 10TH ST W
SAINT PAUL MN
55102-1062
US

IV. Provider business mailing address

2450 W HUNTING PARK AVE
PHILADELPHIA PA
19129-1302
US

V. Phone/Fax

Practice location:
  • Phone: 651-326-3700
  • Fax:
Mailing address:
  • Phone: 215-707-1800
  • Fax: 215-707-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD449854
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number64409
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD185423
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number64409
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: