MEDICARE: DR. CHETAN VAGESH HAMPOLE M.D.

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	207R00000X	Internal Medicine Physician	125-051072	IL
2	207R00000X	Internal Medicine Physician	35-095464	OH
3	207R00000X	Internal Medicine Physician	ME142908	FL
4	207RC0000X	Cardiovascular Disease Physician	35-095464	OH
5	207RI0011X	Interventional Cardiology Physician	ME142908	FL
6	207RI0011X	Interventional Cardiology Physician	35095464	OH
7	207RC0000X	Cardiovascular Disease Physician	ME142908	FL

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659696136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHETAN VAGESH HAMPOLE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 746652
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6652
Country	:	US
Telephone Number	:	904-202-2092
Fax Number	:	904-376-4075

Provider Business Practice Location Address
First Line	:	2310 VILLAGE SQUARE PKWY STE 204
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-6409
Country	:	US
Telephone Number	:	904-224-5185
Fax Number	:	904-376-3202

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

Provider Enumeration Date	:	03/29/2010
Last Update Date	:	01/24/2025

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