Provider Demographics
NPI:1558342592
Name:VASAVADA PANCHAL, NINA (MD)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:VASAVADA PANCHAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2043
Mailing Address - Country:US
Mailing Address - Phone:502-589-4856
Mailing Address - Fax:502-589-5093
Practice Address - Street 1:615 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1715
Practice Address - Country:US
Practice Address - Phone:502-852-5757
Practice Address - Fax:502-852-7643
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY38391207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64077522Medicaid
KY64077522Medicaid
KY0381016Medicare ID - Type Unspecified