Provider Demographics
NPI:1336298199
Name:PANJA, SRINIVAS R (MD)
Entity Type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:R
Last Name:PANJA
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:PO BOX 131913
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77393-1913
Mailing Address - Country:US
Mailing Address - Phone:713-936-2966
Mailing Address - Fax:
Practice Address - Street 1:19701 KINGWOOD DR
Practice Address - Street 2:BLDG 4, STE A
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339
Practice Address - Country:US
Practice Address - Phone:713-936-2966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44673207RE0101X
TXN7647207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34633900Medicaid
WI34633900Medicaid