Provider Demographics
NPI:1295802882
Name:PANZICA, PAUL ANTONY (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:ANTONY
Last Name:PANZICA
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 1:19621 LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-9360
Mailing Address - Country:US
Mailing Address - Phone:708-478-8380
Mailing Address - Fax:708-478-3036
Practice Address - Street 1:19621 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-9360
Practice Address - Country:US
Practice Address - Phone:708-478-8380
Practice Address - Fax:708-478-3036
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095398207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095398Medicaid
ILH10338Medicare UPIN
IL036095398Medicaid