Provider Demographics
NPI:1629508700
Name:PANIKER, CHRISTINE MAURA (DO)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:MAURA
Last Name:PANIKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:885 ROOSEVELT RD STE 202
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6141
Mailing Address - Country:US
Mailing Address - Phone:630-790-1555
Mailing Address - Fax:630-545-3787
Practice Address - Street 1:885 ROOSEVELT RD STE 202
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6141
Practice Address - Country:US
Practice Address - Phone:630-790-1555
Practice Address - Fax:630-545-3787
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036151685208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125070324Medicaid