Provider Demographics
NPI:1629174024
Name:PANCHAL, SUJAL V (MD)
Entity Type:Individual
Prefix:DR
First Name:SUJAL
Middle Name:V
Last Name:PANCHAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUJAL
Other - Middle Name:
Other - Last Name:FADIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 BATSON CT
Mailing Address - Street 2:SUITE 106
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1564
Mailing Address - Country:US
Mailing Address - Phone:815-463-9747
Mailing Address - Fax:815-463-9749
Practice Address - Street 1:100 BATSON CT
Practice Address - Street 2:SUITE 106
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1564
Practice Address - Country:US
Practice Address - Phone:815-463-9747
Practice Address - Fax:815-463-9749
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119020208000000X
CAA82152208000000X
MI4301106399208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036119020Medicaid
CAHSP40248FMedicaid
CAHSP40248FMedicaid
CAA82152Medicare UPIN
CAZZZ93296ZMedicare ID - Type UnspecifiedCOUNTY OF MONTEREY-NMC