MEDICARE: DR. VIPUL N NANAVATI MD, BSME, CAQH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XS0106X	Orthopaedic Hand Surgery Physician	M-14885	ID
2	207X00000X	Orthopaedic Surgery Physician	M-14885	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629074158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VIPUL N NANAVATI MD, BSME, CAQH

Provider Business Mailing Address
First Line	:	6590 W NORWOOD DR
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-8765
Country	:	US
Telephone Number	:	208-506-3665
Fax Number	:	866-554-1818

Provider Business Practice Location Address
First Line	:	3381 W BAVARIA ST
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-5341
Country	:	US
Telephone Number	:	208-639-4800
Fax Number	:	208-639-4801

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	02/25/2022

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