=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710241658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENRY JOSEPH VANPALA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2012
-----------------------------------------------------
Last Update Date | 06/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4822 SIX FORKS RD SUITE 104
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-5269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-795-1399
-----------------------------------------------------
Fax | 919-821-5170
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 DUNHAVEN DR
-----------------------------------------------------
City | GARNER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27529-5104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-795-1399
-----------------------------------------------------
Fax | 919-821-5170
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 005421
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 35424
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 28586
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 010125463
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------