Provider Demographics
NPI:1033292743
Name:PATTANAIK, DEEPAK (MD)
Entity Type:Individual
Prefix:MR
First Name:DEEPAK
Middle Name:
Last Name:PATTANAIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 CRENSHAW RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-3140
Mailing Address - Country:US
Mailing Address - Phone:713-943-8229
Mailing Address - Fax:713-943-9608
Practice Address - Street 1:5030 CRENSHAW RD
Practice Address - Street 2:SUITE 120
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-3140
Practice Address - Country:US
Practice Address - Phone:713-943-8229
Practice Address - Fax:713-943-9608
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4676207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114731602Medicaid
B25397Medicare UPIN
TX84410KMedicare ID - Type Unspecified