Provider Demographics
NPI:1255301701
Name:PANOZZO, SHASHI T (MD)
Entity Type:Individual
Prefix:
First Name:SHASHI
Middle Name:T
Last Name:PANOZZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHASHI
Other - Middle Name:K
Other - Last Name:PANOZZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:259 MAIN ST
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6723
Practice Address - Country:US
Practice Address - Phone:207-846-9013
Practice Address - Fax:207-523-8586
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD18259207Q00000X, 207Q00000X
ME018259207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200526280Medicaid
INP00242796OtherRAILROAD MEDICARE
ME001395201OtherMEDICARE PTAN
IN200526280Medicaid