Provider Demographics
NPI:1093024747
Name:PANCHOLI, JITAL J
Entity Type:Individual
Prefix:
First Name:JITAL
Middle Name:J
Last Name:PANCHOLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JITAL
Other - Middle Name:P
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2450 ATLANTA HWY STE 604
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-1254
Mailing Address - Country:US
Mailing Address - Phone:404-225-2174
Mailing Address - Fax:706-995-6862
Practice Address - Street 1:2450 ATLANTA HWY STE 604
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-1254
Practice Address - Country:US
Practice Address - Phone:404-225-2174
Practice Address - Fax:706-995-6862
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0100032251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116642Medicare UPIN