Provider Demographics
NPI:1417928573
Name:PANCORVO, CARLOS E (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:E
Last Name:PANCORVO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1505 LBJ FWY STE 700
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-6065
Mailing Address - Country:US
Mailing Address - Phone:214-358-2300
Mailing Address - Fax:214-579-6941
Practice Address - Street 1:2651 BOLTON BOONE DR
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2011
Practice Address - Country:US
Practice Address - Phone:214-358-2300
Practice Address - Fax:214-579-6941
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL0482207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXL0482OtherTX MEDICAL LICENSE
TX8864J3Medicare PIN
TX390007153Medicare PIN
TXH21359Medicare UPIN