Healthcare Provider Details

I. General information

NPI: 1699922369
Provider Name (Legal Business Name): PANKAJ PRASUN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 HIGHLAND AVE
MADISON WI
53705-2274
US

IV. Provider business mailing address

1 GUSTAVE L LEVY PL # 1497
NEW YORK NY
10029-6504
US

V. Phone/Fax

Practice location:
  • Phone: 608-262-2507
  • Fax:
Mailing address:
  • Phone: 212-241-6947
  • Fax: 212-860-3316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number3675
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301091882
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: