Healthcare Provider Details

I. General information

NPI: 1689195729
Provider Name (Legal Business Name): UTSAB RAJ PANTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 WOODLAND DR STE A
ELIZABETHTOWN KY
42701-2662
US

IV. Provider business mailing address

1324 WOODLAND DR STE A
ELIZABETHTOWN KY
42701-2662
US

V. Phone/Fax

Practice location:
  • Phone: 270-765-5921
  • Fax: 270-982-3324
Mailing address:
  • Phone: 270-765-5921
  • Fax: 270-982-3324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number58320
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: