Provider Demographics
NPI:1710090105
Name:PANDA, DHIRAJ (MD)
Entity Type:Individual
Prefix:MR
First Name:DHIRAJ
Middle Name:
Last Name:PANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DHIRAJ
Other - Middle Name:K
Other - Last Name:PANDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:528 LIPPINCOTT DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053
Mailing Address - Country:US
Mailing Address - Phone:856-596-6100
Mailing Address - Fax:856-596-7507
Practice Address - Street 1:528 LIPPINCOTT DRIVE
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-596-6100
Practice Address - Fax:856-596-7507
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA 40024208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C53332Medicare UPIN
112898Medicare ID - Type Unspecified