Provider Demographics
NPI:1851482780
Name:DAVE, PANKAJ K (MD)
Entity Type:Individual
Prefix:
First Name:PANKAJ
Middle Name:K
Last Name:DAVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1543 FORD AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-2303
Mailing Address - Country:US
Mailing Address - Phone:734-282-5012
Mailing Address - Fax:734-282-7428
Practice Address - Street 1:1543 FORD AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-2303
Practice Address - Country:US
Practice Address - Phone:734-282-5012
Practice Address - Fax:734-282-7428
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIPD035475208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0824411OtherBCBSM
MI1398464Medicaid
MIA78410OtherHAP
MIA78410OtherHAP