Healthcare Provider Details

I. General information

NPI: 1386933521
Provider Name (Legal Business Name): VABHAVE PAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-4466
  • Fax:
Mailing address:
  • Phone: 551-996-4466
  • Fax: 956-296-1326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-135381
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberQ5890
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA11129900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier352152802
Identifier TypeOTHER
Identifier StateTX
Identifier IssuerMEDICAID-CSHCN
# 2
Identifier352152801
Identifier TypeMEDICAID
Identifier StateTX
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: