Provider Demographics
NPI:1477645539
Name:PANKONIN, MARK WALTER (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WALTER
Last Name:PANKONIN
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 1:1600 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638
Mailing Address - Country:US
Mailing Address - Phone:989-793-0510
Mailing Address - Fax:989-793-9491
Practice Address - Street 1:1600 MIDLAND RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48638
Practice Address - Country:US
Practice Address - Phone:989-793-0510
Practice Address - Fax:989-793-9491
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMP035123207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0722726OtherHEALTHPLUS
MI0732272OtherBLUE CROSS BLUE SHEILD OF
MI080181742OtherRAILROAD MEDICARE
MI0722726OtherHEALTHPLUS