Provider Demographics
NPI:1023142064
Name:PANKIEWICZ, JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:PANKIEWICZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:821 W STATE ST
Mailing Address - Street 2:ROOM 504
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1427
Mailing Address - Country:US
Mailing Address - Phone:414-278-4690
Mailing Address - Fax:414-223-1817
Practice Address - Street 1:821 W STATE ST
Practice Address - Street 2:SUITE 504
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1427
Practice Address - Country:US
Practice Address - Phone:414-278-4690
Practice Address - Fax:414-223-1817
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI29288-0202084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIE21790Medicare UPIN