Provider Demographics
NPI:1497758114
Name:PANKAU, LAWRENCE R (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:R
Last Name:PANKAU
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 1:132 S PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4064
Mailing Address - Country:US
Mailing Address - Phone:847-825-5463
Mailing Address - Fax:
Practice Address - Street 1:132 S PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4064
Practice Address - Country:US
Practice Address - Phone:847-825-5463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036443839207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL395290Medicare ID - Type Unspecified
ILC39831Medicare UPIN