Healthcare Provider Details

I. General information

NPI: 1386940880
Provider Name (Legal Business Name): NIBONDH VACHARAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 ACADEMY LN
ELKINS PARK PA
19027-2514
US

IV. Provider business mailing address

1413 ACADEMY LN
ELKINS PARK PA
19027-2514
US

V. Phone/Fax

Practice location:
  • Phone: 215-782-1047
  • Fax:
Mailing address:
  • Phone: 215-782-1047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD033586L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: