Healthcare Provider Details

I. General information

NPI: 1972730547
Provider Name (Legal Business Name): VIPUL KHETARPAUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11155 DUNN RD DIV SURG VASCULAR, STE 108N
SAINT LOUIS MO
63136-6150
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-273-7373
  • Fax: 888-840-6225
Mailing address:
  • Phone: 314-273-7373
  • Fax: 888-840-6225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2019009761
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number2019009761
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: