Provider Demographics
NPI:1366641540
Name:PANDYA INTERNAL MEDICINE CLINIC, LLC
Entity Type:Organization
Organization Name:PANDYA INTERNAL MEDICINE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHESH
Authorized Official - Middle Name:
Authorized Official - Last Name:PANDYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-463-2172
Mailing Address - Street 1:603 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-4941
Mailing Address - Country:US
Mailing Address - Phone:337-463-2172
Mailing Address - Fax:337-462-3243
Practice Address - Street 1:603 S PINE ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4941
Practice Address - Country:US
Practice Address - Phone:337-463-2172
Practice Address - Fax:337-462-3243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05773R207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1320692Medicaid
B61710Medicare UPIN