Provider Demographics
NPI:1700824612
Name:JANDWANI, PANKAJ (MD)
Entity Type:Individual
Prefix:DR
First Name:PANKAJ
Middle Name:
Last Name:JANDWANI
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:PO BOX 173
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-0173
Mailing Address - Country:US
Mailing Address - Phone:989-463-5740
Mailing Address - Fax:888-346-7607
Practice Address - Street 1:300 E WARWICK DR
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1014
Practice Address - Country:US
Practice Address - Phone:989-463-5740
Practice Address - Fax:888-346-7607
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070136174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1102911791OtherBCBS
MI1012007OtherMCLAREN
MIP109253OtherBLUECARE NETWORK
MI4639991Medicaid
MI4270247Medicaid
MI4565225Medicaid
MI4671470Medicaid
MI1105910131OtherBCBS
MI1012005OtherMCLAREN
MIN74560005Medicare PIN
1102911791OtherBCBS
MI4639991Medicaid
MIM17400027Medicare PIN
MIP00193064Medicare PIN
MIP00167207Medicare PIN