Provider Demographics
NPI:1477647923
Name:PRITHVIRAJ, PANJU (MD)
Entity Type:Individual
Prefix:
First Name:PANJU
Middle Name:
Last Name:PRITHVIRAJ
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 1:615 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452
Mailing Address - Country:US
Mailing Address - Phone:419-734-3131
Mailing Address - Fax:419-732-4046
Practice Address - Street 1:615 FULTON ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452
Practice Address - Country:US
Practice Address - Phone:419-734-3131
Practice Address - Fax:419-732-4046
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-051822207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH342850OtherANTHEM BCBS OF OHIO
OH0585755Medicaid
OH0585755Medicaid
OH342850OtherANTHEM BCBS OF OHIO