Healthcare Provider Details

I. General information

NPI: 1134066442
Provider Name (Legal Business Name): AYUSH SURESHBHAI THAKKAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE CARILION ROANOKE MEMORIAL HOSPITAL
ROANOKE VA
24014
US

IV. Provider business mailing address

1906 BELLEVIEW AVE SE GRADUATE MEDICAL EDUCATION OFFICE
ROANOKE VA
24014
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-7000
  • Fax:
Mailing address:
  • Phone: 540-981-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: