Provider Demographics
NPI:1063424893
Name:PANCHAL, KALPESHKUMAR KANTILAL (MD)
Entity type:Individual
Prefix:
First Name:KALPESHKUMAR
Middle Name:KANTILAL
Last Name:PANCHAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-245-3107
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN STREET
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219
Practice Address - Country:US
Practice Address - Phone:513-584-1584
Practice Address - Fax:513-584-0431
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068846207R00000X
OH35-0913522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2946236Medicaid
KY7100162530Medicaid
MI4551319Medicaid
MI4551319Medicaid
OHH041260Medicare PIN