Provider Demographics
NPI:1467571463
Name:PANTHANGI, VEENA (MD)
Entity Type:Individual
Prefix:DR
First Name:VEENA
Middle Name:
Last Name:PANTHANGI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21099 MASONIC BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-1045
Mailing Address - Country:US
Mailing Address - Phone:586-296-6213
Mailing Address - Fax:586-296-8180
Practice Address - Street 1:21099 MASONIC BLVD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-1045
Practice Address - Country:US
Practice Address - Phone:586-296-6213
Practice Address - Fax:586-286-8180
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301081639207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5186442Medicaid
MIVP081639OtherMICHIGAN PHYSICIAN LICENS
MI700E011730OtherBCBSM GROUP NUMBER
MI700E031610OtherBCBS GROUP NUMBER
MIM92600037Medicare PIN
MIMI3971Medicare PIN