Basic Information
| Provider Information | |||||||||
| NPI: | 1891126330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VORA | ||||||||
| FirstName: | KETUL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000, DEPT 351 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017589900 | ||||||||
| FaxNumber: | 9017522335 | ||||||||
| Practice Location | |||||||||
| Address1: | 4250 BETHEL RD | ||||||||
| Address2: | |||||||||
| City: | OLIVE BRANCH | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386548737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015161290 | ||||||||
| FaxNumber: | 9015161220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2013 | ||||||||
| LastUpdateDate: | 12/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/27/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 275562 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 59450 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 27130 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.