Provider Demographics
NPI:1750739900
Name:PAMNANI, SHITALDAS JAMANDAS (MD)
Entity type:Individual
Prefix:
First Name:SHITALDAS
Middle Name:JAMANDAS
Last Name:PAMNANI
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 1:530 PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-3903
Mailing Address - Country:US
Mailing Address - Phone:815-875-2811
Mailing Address - Fax:815-876-2119
Practice Address - Street 1:535 PARK AVE E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356
Practice Address - Country:US
Practice Address - Phone:815-875-4531
Practice Address - Fax:815-876-2118
Is Sole Proprietor?:No
Enumeration Date:2016-05-28
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN23676207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036149196Medicaid