Healthcare Provider Details

I. General information

NPI: 1083239792
Provider Name (Legal Business Name): KRUTARTH KANDARP PANDYA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date: 01/18/2022
Reactivation Date: 03/08/2022

III. Provider practice location address

1350 EAST MARKET STREET 7TH FLOOR
WARREN OH
44483
US

IV. Provider business mailing address

9500 EUCLID AVE
CLEVELAND OH
44195-0002
US

V. Phone/Fax

Practice location:
  • Phone: 330-841-9647
  • Fax: 330-841-9645
Mailing address:
  • Phone: 216-636-2035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35.148443
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: