Provider Demographics
NPI:1164416210
Name:ATHMARAM, PANCHARATHNA K (MD)
Entity Type:Individual
Prefix:
First Name:PANCHARATHNA
Middle Name:K
Last Name:ATHMARAM
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 1:661 PARK AVE E
Mailing Address - Street 2:SUITE A
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44905-2880
Mailing Address - Country:US
Mailing Address - Phone:419-526-3999
Mailing Address - Fax:419-526-1137
Practice Address - Street 1:661 PARK AVE E
Practice Address - Street 2:SUITE A
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44905-2880
Practice Address - Country:US
Practice Address - Phone:419-526-3999
Practice Address - Fax:419-526-1137
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051805207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0585424Medicaid
110188865OtherRAILROAD MEDICARE
341506280OtherEIN
110188865OtherRAILROAD MEDICARE
A82149Medicare UPIN