Provider Demographics
NPI:1639177041
Name:PANESAR, INDERJIT SINGH (DPM)
Entity Type:Individual
Prefix:DR
First Name:INDERJIT
Middle Name:SINGH
Last Name:PANESAR
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 1:1 EDMUNDSON PL
Mailing Address - Street 2:STE 500
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4619
Mailing Address - Country:US
Mailing Address - Phone:712-323-5333
Mailing Address - Fax:712-323-3252
Practice Address - Street 1:1 EDMUNDSON PL
Practice Address - Street 2:STE 500
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4619
Practice Address - Country:US
Practice Address - Phone:712-323-5333
Practice Address - Fax:712-323-3252
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE252213E00000X
IA500213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1080697Medicaid
IA20945OtherWELLMARK
U29154Medicare UPIN
IA20945Medicare PIN
NE273624Medicare PIN