Provider Demographics
NPI:1891843132
Name:MAHADEVAN, PANKAJAM V (MD)
Entity Type:Individual
Prefix:DR
First Name:PANKAJAM
Middle Name:V
Last Name:MAHADEVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12074 NEWCASTLE AVE
Mailing Address - Street 2:APT 1211
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8998
Mailing Address - Country:US
Mailing Address - Phone:225-293-4478
Mailing Address - Fax:
Practice Address - Street 1:5151 PLANK RD
Practice Address - Street 2:SUITE NUMBER 38
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-3501
Practice Address - Country:US
Practice Address - Phone:225-356-2006
Practice Address - Fax:225-355-1144
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD025141208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1537691Medicaid
LA1537691Medicaid
LAH43977Medicare UPIN