Healthcare Provider Details

I. General information

NPI: 1114982154
Provider Name (Legal Business Name): PERNANKEL D NAYAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PERNANKEL DHARMADEV L. NAYAK M.D.

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 W VIRGINIA AVE
EFFINGHAM IL
62401-2258
US

IV. Provider business mailing address

414 W VIRGINIA AVE P O BOX 1169
EFFINGHAM IL
62401-2258
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-9738
  • Fax: 217-342-9806
Mailing address:
  • Phone: 217-342-9738
  • Fax: 217-342-9806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036054866
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: