Healthcare Provider Details

I. General information

NPI: 1669631099
Provider Name (Legal Business Name): MEENAKSHI DEVI PALANI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 AVENUE O
FORT MADISON IA
52627-9601
US

IV. Provider business mailing address

5409 AVENUE O
FORT MADISON IA
52627-9601
US

V. Phone/Fax

Practice location:
  • Phone: 319-376-2134
  • Fax: 319-376-2188
Mailing address:
  • Phone: 319-376-2134
  • Fax: 319-376-2188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number53621-21
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4247
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1669631099
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: