Provider Demographics
NPI:1659696136
Name:HAMPOLE, CHETAN VAGESH (MD)
Entity Type:Individual
Prefix:DR
First Name:CHETAN
Middle Name:VAGESH
Last Name:HAMPOLE
Suffix:
Gender:M
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:PO BOX 43667
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-3667
Mailing Address - Country:US
Mailing Address - Phone:904-720-0599
Mailing Address - Fax:904-376-4036
Practice Address - Street 1:1747 BAPTIST CLAY DR STE 320
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-8503
Practice Address - Country:US
Practice Address - Phone:904-224-5185
Practice Address - Fax:904-278-7284
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-051072207R00000X
OH35-095464207R00000X, 207RC0000X
FLME142908207R00000X, 207RI0011X
OH35095464207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3025372Medicaid
OH9389631Medicare PIN
OH3025372Medicaid