Healthcare Provider Details

I. General information

NPI: 1952694531
Provider Name (Legal Business Name): NATHAN P VAKHARIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 A PETERSON MEMORIAL DR
NIAGARA WI
54151-9246
US

IV. Provider business mailing address

824 A PETERSON MEMORIAL DR
NIAGARA WI
54151-9246
US

V. Phone/Fax

Practice location:
  • Phone: 608-843-6460
  • Fax:
Mailing address:
  • Phone: 608-843-6460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301105329
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number59487
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number59487-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: