Healthcare Provider Details

I. General information

NPI: 1457353344
Provider Name (Legal Business Name): MAHESH R PANDYA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 S PINE ST
DERIDDER LA
70634-4941
US

IV. Provider business mailing address

603 S PINE ST
DERIDDER LA
70634-4941
US

V. Phone/Fax

Practice location:
  • Phone: 337-463-2172
  • Fax: 337-462-3243
Mailing address:
  • Phone: 337-463-2172
  • Fax: 337-462-3243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberL05773R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: