Provider Demographics
NPI:1629074158
Name:NANAVATI, VIPUL N (MD, BSME, CAQH)
Entity Type:Individual
Prefix:DR
First Name:VIPUL
Middle Name:N
Last Name:NANAVATI
Suffix:
Gender:M
Credentials:MD, BSME, CAQH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6590 W NORWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8765
Mailing Address - Country:US
Mailing Address - Phone:208-506-3665
Mailing Address - Fax:866-554-1818
Practice Address - Street 1:3381 W BAVARIA ST
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5341
Practice Address - Country:US
Practice Address - Phone:208-639-4800
Practice Address - Fax:208-639-4801
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-14885207XS0106X, 207X00000X
PAMD074409L207X00000X
NY236620207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1629074158Medicaid
NYI36171Medicare UPIN
NYRA7456Medicare PIN
NY2667825Medicaid