Provider Demographics
NPI:1629047964
Name:JEYAKUMAR, PANCH (MD)
Entity Type:Individual
Prefix:DR
First Name:PANCH
Middle Name:
Last Name:JEYAKUMAR
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 1:200 S MANCHESTER AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3219
Mailing Address - Country:US
Mailing Address - Phone:714-456-2986
Mailing Address - Fax:
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-880-7812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42736207R00000X, 207RC0200X
CAA042736207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00000953OtherMEDICARE RR
CA00A427360Medicaid
WA42736HMedicare PIN
CAWA42736KMedicare PIN
CAP00000953OtherMEDICARE RR
CAB45295Medicare UPIN
CAWA42736IMedicare PIN
CAWA42736FMedicare PIN