Basic Information
| Provider Information | |||||||||
| NPI: | 1053573444 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANCHAL | ||||||||
| FirstName: | AJAY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 HIDDEN PINES CT | ||||||||
| Address2: | |||||||||
| City: | EAST AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140511688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166896388 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6044 MAIN ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142216883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168337112 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 267266 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 03723104 | 05 | NY | MEDICAID |