Healthcare Provider Details
I. General information
NPI: 1265424212
Provider Name (Legal Business Name): PARUL G PATHAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 08/16/2005
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
1160 JOLIET ST SUITE 103
DYER IN
46311-2096
US
IV. Provider business mailing address
1160 JOLIET ST SUITE 103
DYER IN
46311-2096
US
V. Phone/Fax
- Phone: 219-322-8534
- Fax: 219-865-9072
- Phone: 219-322-8534
- Fax: 219-865-9072
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 208000000X |
| Taxonomy | Pediatrics Physician |
| License Number | 01057543A |
| License Number State | IN |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 200444360 |
| Identifier Type | MEDICAID |
| Identifier State | IN |
| Identifier Issuer | |
| # 2 | |
| Identifier | 32-0149967 |
| Identifier Type | OTHER |
| Identifier State | IN |
| Identifier Issuer | EMPLOYER TAX ID |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone: