Basic Information
Provider Information | |||||||||
NPI: | 1306133921 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAGHDAL | ||||||||
FirstName: | DIGANTKUMAR | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 299 FOREST LN | ||||||||
Address2: |   | ||||||||
City: | BRANSON | ||||||||
State: | MO | ||||||||
PostalCode: | 656168680 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4300 LONDONDERRY RD | ||||||||
Address2: |   | ||||||||
City: | HARRISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 171095317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172318772 | ||||||||
FaxNumber: | 7172318435 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2011 | ||||||||
LastUpdateDate: | 12/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 15690 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 282NC0060X | 2014022150 | MO | N |   | Hospitals | General Acute Care Hospital | Critical Access | 208M00000X | MD469697 | PA | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 103754875 | 05 | PA |   | MEDICAID |