Healthcare Provider Details

I. General information

NPI: 1548285455
Provider Name (Legal Business Name): JAYESH PANCHAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 S KELLY AVE
EDMOND OK
73013
US

IV. Provider business mailing address

2505 S KELLY AVE
EDMOND OK
73013
US

V. Phone/Fax

Practice location:
  • Phone: 405-340-9949
  • Fax: 405-330-2132
Mailing address:
  • Phone: 405-340-9949
  • Fax: 405-330-2132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number20347
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: