Provider Demographics
NPI:1205878790
Name:PAWA, PRATHEEP (MD)
Entity type:Individual
Prefix:
First Name:PRATHEEP
Middle Name:
Last Name:PAWA
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 1:1320 MERCY DR NW
Mailing Address - Street 2:SECOND FLOOR MERCY HALL
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-2614
Mailing Address - Country:US
Mailing Address - Phone:330-471-5930
Mailing Address - Fax:330-471-5938
Practice Address - Street 1:125 CANTON RD NW
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:44615-1009
Practice Address - Country:US
Practice Address - Phone:330-627-7641
Practice Address - Fax:330-627-5796
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35085326204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000386187OtherANTHEM BC/BS URGENT CARE
OHP00314038OtherRAILROAD CARE
OH000000484955OtherANTHEM, BC/BS OFFICE
OH340714684101OtherCAREOURCE URGENT CARE
OH196433OtherWELLCARE URGENT CARE
OH340714684105OtherCARESOURCE OFFICE
OH352588OtherWELLCARE OFFICE
OH2700189Medicaid
OHP00314038OtherRAILROAD CARE
OH4180312Medicare PIN
OH4180314Medicare PIN