Basic Information
Provider Information | |||||||||
NPI: | 1407808454 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PANCHAL | ||||||||
FirstName: | NEERAJ | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 23540 | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921933540 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585650950 | ||||||||
FaxNumber: | 8585652863 | ||||||||
Practice Location | |||||||||
Address1: | 8745 AERO DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921231761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585650950 | ||||||||
FaxNumber: | 8585652863 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 09/19/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A83142 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | GR0083812 | 05 | CA |   | MEDICAID | GR0083817 | 05 | CA |   | MEDICAID | GR0083815 | 05 | CA |   | MEDICAID | ZZZ75341Z | 05 | CA |   | MEDICAID | GR0083810 | 05 | CA |   | MEDICAID | GR0083811 | 05 | CA |   | MEDICAID | GR0083814 | 05 | CA |   | MEDICAID | GR0083816 | 05 | CA |   | MEDICAID | GR0083813 | 05 | CA |   | MEDICAID |