Healthcare Provider Details

I. General information

NPI: 1417683962
Provider Name (Legal Business Name): SMITA PANCHOLIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 06/15/2024
Certification Date: 06/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E MARSHALL ST
RICHMOND VA
23298-5023
US

IV. Provider business mailing address

VCUHS GME ADMINISTRATION BOX 980257
RICHMOND VA
23298-0257
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-8048
  • Fax: 804-828-0854
Mailing address:
  • Phone: 804-828-9783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0116039351
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: