Provider Demographics
NPI:1245290378
Name:PATHAK, VIMAL B (MD)
Entity type:Individual
Prefix:
First Name:VIMAL
Middle Name:B
Last Name:PATHAK
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 1:1000 E 80TH PLACE
Mailing Address - Street 2:SUITE 308 SOUTH TOWER
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410
Mailing Address - Country:US
Mailing Address - Phone:219-736-8118
Mailing Address - Fax:219-736-7583
Practice Address - Street 1:1000 E 80TH PLACE
Practice Address - Street 2:SUITE 308 SOUTH TOWER
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:219-736-8118
Practice Address - Fax:219-736-7583
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034936A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000328376OtherANTHEM BC/BS
B29270Medicare UPIN
IN222180AMedicare PIN
INP00270790Medicare PIN