Provider Demographics
NPI:1700054939
Name:PATHAK, HIMANSHU (MD)
Entity Type:Individual
Prefix:
First Name:HIMANSHU
Middle Name:
Last Name:PATHAK
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 1:619 E MASON ST
Mailing Address - Street 2:SUITE 4P57
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1034
Mailing Address - Country:US
Mailing Address - Phone:217-788-0706
Mailing Address - Fax:217-525-2535
Practice Address - Street 1:619 E MASON ST
Practice Address - Street 2:SUITE 4P57
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1034
Practice Address - Country:US
Practice Address - Phone:217-788-0706
Practice Address - Fax:217-525-2535
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036134886207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036134886Medicaid
35897OtherMAIMONIDES MEDICAL CENTER
ILP01361174OtherRAILROAD
35897OtherMAIMONIDES MEDICAL CENTER