Healthcare Provider Details

I. General information

NPI: 1639283542
Provider Name (Legal Business Name): INDIRA PANTHAGANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-6581
  • Fax: 860-714-8311
Mailing address:
  • Phone: 860-714-4404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberNONE
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number044750
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number44750
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number44750
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: