Healthcare Provider Details

I. General information

NPI: 1962817783
Provider Name (Legal Business Name): JONATHAN DANIEL PANKOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13656 BRETON RIDGE ST # AH
HOUSTON TX
77070-6081
US

IV. Provider business mailing address

13656 BRETON RIDGE ST # AH
HOUSTON TX
77070-6081
US

V. Phone/Fax

Practice location:
  • Phone: 281-429-8780
  • Fax: 281-763-7930
Mailing address:
  • Phone: 281-429-8780
  • Fax: 281-763-7930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04-39389
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberS5041
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: