1891843132 NPI number — DR. PANKAJAM V MAHADEVAN M.D

Table of content: DR. PANKAJAM V MAHADEVAN M.D (NPI 1891843132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891843132 NPI number — DR. PANKAJAM V MAHADEVAN M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHADEVAN
Provider First Name:
PANKAJAM
Provider Middle Name:
V
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891843132
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12074 NEWCASTLE AVE
Provider Second Line Business Mailing Address:
APT 1211
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-8998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-293-4478
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5151 PLANK RD
Provider Second Line Business Practice Location Address:
SUITE NUMBER 38
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70805-3501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-356-2006
Provider Business Practice Location Address Fax Number:
225-355-1144
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  MD025141 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1537691 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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