Provider Demographics
NPI:1568679843
Name:PANCHAL, AMIESHA S (MD)
Entity Type:Individual
Prefix:
First Name:AMIESHA
Middle Name:S
Last Name: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 1:195 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-6701
Mailing Address - Country:US
Mailing Address - Phone:781-338-0500
Mailing Address - Fax:
Practice Address - Street 1:195 CANAL ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-6701
Practice Address - Country:US
Practice Address - Phone:781-338-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA257728207Q00000X
VA0116017777390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1568679843OtherNPI
MA110098967AMedicaid