Provider Demographics
NPI:1164593083
Name:GNANESWARAN, PANCHADCHARAM (MD)
Entity Type:Individual
Prefix:
First Name:PANCHADCHARAM
Middle Name:
Last Name:GNANESWARAN
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:P O BOX 3012
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804
Mailing Address - Country:US
Mailing Address - Phone:302-224-5678
Mailing Address - Fax:302-224-2848
Practice Address - Street 1:204 SOUTH ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5633
Practice Address - Country:US
Practice Address - Phone:410-392-8000
Practice Address - Fax:410-392-5990
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM37596207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD52827004OtherMD BLUE CROSS
F75896Medicare UPIN
MD52827004OtherMD BLUE CROSS