Healthcare Provider Details

I. General information

NPI: 1255560595
Provider Name (Legal Business Name): PANKAJ P DANGLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3536 VISTA AVE
SAINT LOUIS MO
63104-1006
US

IV. Provider business mailing address

500 22ND ST S APARTMENT -A
BIRMINGHAM AL
35233-3110
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8317
  • Fax: 314-268-5466
Mailing address:
  • Phone: 314-932-5179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01086725A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number01086725A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2009017783
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number35045
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: