Provider Demographics
NPI:1467534842
Name:MAMTORA, PANKAJ K (MD)
Entity Type:Individual
Prefix:
First Name:PANKAJ
Middle Name:K
Last Name:MAMTORA
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 1:5629 METROPOLITAN AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1975
Mailing Address - Country:US
Mailing Address - Phone:718-418-0300
Mailing Address - Fax:718-418-0301
Practice Address - Street 1:5629 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-1975
Practice Address - Country:US
Practice Address - Phone:718-418-0300
Practice Address - Fax:718-418-0301
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183635207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01456968Medicaid
NY29I692OtherEMPIRE BS BC ON NY
NY02007Medicare PIN
NY01456968Medicaid