Healthcare Provider Details

I. General information

NPI: 1366518342
Provider Name (Legal Business Name): PANKAJ NANUBHAI MISTRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 S SUNSET AVE STE 101
WEST COVINA CA
91790-3410
US

IV. Provider business mailing address

PO BOX 4219
WEST COVINA CA
91791-0219
US

V. Phone/Fax

Practice location:
  • Phone: 626-919-5437
  • Fax: 626-919-5439
Mailing address:
  • Phone: 626-919-5437
  • Fax: 626-919-5439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA44860
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberA44860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: