Basic Information
Provider Information | |||||||||
NPI: | 1659576635 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ACHARYA | ||||||||
FirstName: | VINITA | ||||||||
MiddleName: | JAYANT | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THAKUR | ||||||||
OtherFirstName: | VINITA | ||||||||
OtherMiddleName: | DATTATRAYA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 858 | ||||||||
Address2: | MC A410 | ||||||||
City: | HERSHEY | ||||||||
State: | PA | ||||||||
PostalCode: | 170330858 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002431455 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 30 HOPE DR STE 1300 | ||||||||
Address2: |   | ||||||||
City: | HERSHEY | ||||||||
State: | PA | ||||||||
PostalCode: | 170332036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175313828 | ||||||||
FaxNumber: | 7175314694 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2007 | ||||||||
LastUpdateDate: | 11/26/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD438385 | PA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 390200000X | 2004019665 | MO | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
ID Information
ID | Type | State | Issuer | Description | 1024392970001 | 05 | PA |   | MEDICAID |