Provider Demographics
NPI:1912197278
Name:PANCHOLY, PAVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAVAN
Middle Name:
Last Name:PANCHOLY
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 1:5707- N. 22ND STREET
Mailing Address - Street 2:MENTAL HEALTH CARE, INC.
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-4350
Mailing Address - Country:US
Mailing Address - Phone:813-272-2878
Mailing Address - Fax:813-272-3766
Practice Address - Street 1:5707- N. 22ND STREET
Practice Address - Street 2:MENTAL HEALTH CARE, INC.
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4350
Practice Address - Country:US
Practice Address - Phone:813-272-2878
Practice Address - Fax:813-272-3766
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 1006202084P0800X
LAMD.2007752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry