Provider Demographics
NPI:1629004817
Name:PANACKAL, ANIL A (MD, SM, FACP)
Entity Type:Individual
Prefix:DR
First Name:ANIL
Middle Name:A
Last Name:PANACKAL
Suffix:
Gender:M
Credentials:MD, SM, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CLINICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814
Mailing Address - Country:US
Mailing Address - Phone:301-496-1211
Mailing Address - Fax:
Practice Address - Street 1:10 CLINICAL CENTER
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814
Practice Address - Country:US
Practice Address - Phone:301-496-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0063530207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2108526Medicaid
MA0036323OtherNEIGHBORHOOD HEALTH
MA462316OtherTUFTS
MAJ29345OtherBLUE CROSS
MAAA43438OtherHARVARD PILGRIM
MAI33781Medicare UPIN
MAA39162Medicare ID - Type Unspecified