Healthcare Provider Details

I. General information

NPI: 1376599647
Provider Name (Legal Business Name): PANKAJ KIRTIKANT VYAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL DR
BENSON NC
27504-1177
US

IV. Provider business mailing address

1 MEDICAL DR
BENSON NC
27504-1177
US

V. Phone/Fax

Practice location:
  • Phone: 919-894-5787
  • Fax: 919-207-2039
Mailing address:
  • Phone: 919-894-5787
  • Fax: 919-207-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number31087
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: