Basic Information
| Provider Information | |||||||||
| NPI: | 1174728372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHANPARA | ||||||||
| FirstName: | VIPUL | ||||||||
| MiddleName: | DHARAMSHI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 PINE GROVE AVE | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109893300 | ||||||||
| FaxNumber: | 8109852671 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 PINE GROVE AVE | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109893300 | ||||||||
| FaxNumber: | 8109852671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301116733 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 50209 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00414061 | 01 | WI | MEDICARE RAILROAD | OTHER | 34791600 | 05 | WI | MEDICAID |