Basic Information
Provider Information | |||||||||
NPI: | 1659696136 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAMPOLE | ||||||||
FirstName: | CHETAN | ||||||||
MiddleName: | VAGESH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 43667 | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322033667 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9047200599 | ||||||||
FaxNumber: | 9043764036 | ||||||||
Practice Location | |||||||||
Address1: | 1747 BAPTIST CLAY DR STE 320 | ||||||||
Address2: |   | ||||||||
City: | FLEMING ISLAND | ||||||||
State: | FL | ||||||||
PostalCode: | 320038503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042245185 | ||||||||
FaxNumber: | 9042787284 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2010 | ||||||||
LastUpdateDate: | 04/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125-051072 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 35-095464 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | ME142908 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RC0000X | 35-095464 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 35095464 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | ME142908 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | 3025372 | 05 | OH |   | MEDICAID |