1063754125 NPI number — DR. PRERNA RAJ PANDYA M.D.

Table of content: DR. PRERNA RAJ PANDYA M.D. (NPI 1063754125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063754125 NPI number — DR. PRERNA RAJ PANDYA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANDYA
Provider First Name:
PRERNA
Provider Middle Name:
RAJ
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:
RAJ
Provider Other First Name:
PRERNA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063754125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9200 W WISCONSIN AVENUE
Provider Second Line Business Mailing Address:
UROGYNECOLOGY
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-3522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-805-3666
Provider Business Mailing Address Fax Number:
414-805-6622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9200 W WISCONSIN AVENUE
Provider Second Line Business Practice Location Address:
UROGYNECOLOGY
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-3522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-805-3666
Provider Business Practice Location Address Fax Number:
414-805-6622
Provider Enumeration Date:
03/26/2013

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: 207VF0040X , with the licence number:  72958 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1063754125 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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