Provider Demographics
NPI:1780789784
Name:BANERJEE, DIPALI (MD)
Entity type:Individual
Prefix:
First Name:DIPALI
Middle Name:
Last Name:BANERJEE
Suffix:
Gender:F
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:PO BOX 2486
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2486
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2875 W 19TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3501
Practice Address - Country:US
Practice Address - Phone:773-665-3045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058352207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00332720OtherRAILROAD MEDICARE- PSIL
364125320002OtherCHAMPUS
IL01621061OtherBCBS PATHOLOGY CHP
IL036058352Medicaid
IL01636148OtherBCBS PATHOLOGY SERVICE IL
IL220033246OtherRAILROAD MEDICARE-PATHOLOGY CHP
132302200OtherDEPT OF LABOR
364125320002OtherCHAMPUS
G35832Medicare UPIN
ILK26490Medicare PIN