Basic Information
| Provider Information | |||||||||
| NPI: | 1386933521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAL | ||||||||
| FirstName: | VABHAVE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 30 PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076011915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5519964466 | ||||||||
| FaxNumber: | 9562961326 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076011915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5519964466 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2011 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-135381 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | Q5890 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 25MA11129900 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 352152802 | 01 | TX | MEDICAID-CSHCN | OTHER | 352152801 | 05 | TX | MEDICAID |