Provider Demographics
NPI:1689195729
Name:PANTA, UTSAB RAJ (MD)
Entity Type:Individual
Prefix:
First Name:UTSAB
Middle Name:RAJ
Last Name:PANTA
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 1:2020 INDIAN RIDGE RD APT 124
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4286
Mailing Address - Country:US
Mailing Address - Phone:682-812-5513
Mailing Address - Fax:
Practice Address - Street 1:178 MAPLE CT
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-3156
Practice Address - Country:US
Practice Address - Phone:423-439-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine