Provider Demographics
NPI:1619107042
Name:PANCHAM, KRISHNA (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:
Last Name:PANCHAM
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-6483
Mailing Address - Fax:682-885-3113
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-6299
Practice Address - Fax:682-885-1090
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY479742080P0214X
TXT03062080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology