Provider Demographics
NPI:1578638433
Name:PANNELL, RICHARD WINGATE (DPM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WINGATE
Last Name:PANNELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 BOYNTON AVENUE
Mailing Address - Street 2:#2K
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-4748
Mailing Address - Country:US
Mailing Address - Phone:718-378-0735
Mailing Address - Fax:
Practice Address - Street 1:215 WEST 125TH ST
Practice Address - Street 2:RENAISSANCE HCN 2ND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027
Practice Address - Country:US
Practice Address - Phone:212-932-6514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0026771213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00406184Medicaid
NY00406184Medicaid