Provider Demographics
NPI:1124120449
Name:SHROFF, PANKAJRAI S (MD)
Entity type:Individual
Prefix:
First Name:PANKAJRAI
Middle Name:S
Last Name:SHROFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7937 US HWY 165
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:LA
Mailing Address - Zip Code:71418
Mailing Address - Country:US
Mailing Address - Phone:318-649-2621
Mailing Address - Fax:318-649-5885
Practice Address - Street 1:7937 US HWY 165
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:LA
Practice Address - Zip Code:71418
Practice Address - Country:US
Practice Address - Phone:318-649-2621
Practice Address - Fax:318-649-5885
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05693R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1319350Medicaid
LAB60911Medicare UPIN
LA5K501Medicare ID - Type Unspecified