Provider Demographics
NPI:1154313484
Name:PANNELL, CARMEN DENISE (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:DENISE
Last Name:PANNELL
Suffix:
Gender:F
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:PO BOX 1758
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-1758
Mailing Address - Country:US
Mailing Address - Phone:212-234-6336
Mailing Address - Fax:
Practice Address - Street 1:460 W 150TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-2707
Practice Address - Country:US
Practice Address - Phone:212-234-6336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2010-02-25
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
NY1698682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02645196Medicaid
NYRA6229Medicare ID - Type Unspecified
NY02645196Medicaid