Provider Demographics
NPI:1205886967
Name:TYAGI, PANKAJ K (OTR)
Entity type:Individual
Prefix:
First Name:PANKAJ
Middle Name:K
Last Name:TYAGI
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4417 S HIDDEN WAY ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-6602
Mailing Address - Country:US
Mailing Address - Phone:812-201-1338
Mailing Address - Fax:
Practice Address - Street 1:4417 S HIDDEN WAY ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-6602
Practice Address - Country:US
Practice Address - Phone:812-201-1338
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001448A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ17852Medicare UPIN