Provider Demographics
NPI:1770576753
Name:KISHORE, PANKAJ (MD)
Entity type:Individual
Prefix:DR
First Name:PANKAJ
Middle Name:
Last Name:KISHORE
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 1:413 KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-3231
Mailing Address - Country:US
Mailing Address - Phone:518-462-0253
Mailing Address - Fax:518-462-0262
Practice Address - Street 1:413 KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-3231
Practice Address - Country:US
Practice Address - Phone:518-462-0253
Practice Address - Fax:518-462-0262
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2316642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02565800Medicaid
NY02565800Medicaid
NYRA5692Medicare ID - Type Unspecified