Provider Demographics
NPI:1679984546
Name:DARUWALLA, VISTASP (MD)
Entity Type:Individual
Prefix:
First Name:VISTASP
Middle Name:
Last Name:DARUWALLA
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 2427
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39442-2427
Mailing Address - Country:US
Mailing Address - Phone:601-428-1000
Mailing Address - Fax:
Practice Address - Street 1:1220 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4355
Practice Address - Country:US
Practice Address - Phone:814-534-9104
Practice Address - Fax:814-534-3290
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT206379207R00000X
MS276892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine