Provider Demographics
NPI:1023026390
Name:PANKOWSKY, JAIME (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:PANKOWSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAIME
Other - Middle Name:
Other - Last Name:PANKOWSKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:454 PECAN WAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1532
Mailing Address - Country:US
Mailing Address - Phone:210-248-7308
Mailing Address - Fax:210-878-4032
Practice Address - Street 1:111 DALLAS ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-1201
Practice Address - Country:US
Practice Address - Phone:210-248-7308
Practice Address - Fax:210-878-4032
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE 4132207QA0505X
TXE4132208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX032103601Medicaid
TX0321036-01Medicaid
TX032103601Medicaid
TX00B512Medicare PIN