MEDICARE: PANKAJ K MAMTORA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	183635	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	29I692	OTHER	NY	EMPIRE BS BC ON NY

General Provider Information

NPI Number	:	1467534842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PANKAJ K MAMTORA MD

Provider Business Mailing Address
First Line	:	5629 METROPOLITAN AVE
Second Line	:
City	:	RIDGEWOOD
State	:	NY
Zip	:	11385-1975
Country	:	US
Telephone Number	:	718-418-0300
Fax Number	:	718-418-0301

Provider Business Practice Location Address
First Line	:	5629 METROPOLITAN AVE
Second Line	:
City	:	RIDGEWOOD
State	:	NY
Zip	:	11385-1975
Country	:	US
Telephone Number	:	718-418-0300
Fax Number	:	718-418-0301

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	06/02/2023

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