Provider Demographics
NPI:1194043315
Name:PANKOW, NIKOLAUS WIM (MD)
Entity type:Individual
Prefix:MR
First Name:NIKOLAUS
Middle Name:WIM
Last Name:PANKOW
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 1:2465 S STATE ROAD 7 STE 800
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-9348
Mailing Address - Country:US
Mailing Address - Phone:561-784-4930
Mailing Address - Fax:833-625-1630
Practice Address - Street 1:2465 S STATE ROAD 7 STE 800
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-9348
Practice Address - Country:US
Practice Address - Phone:561-798-3030
Practice Address - Fax:561-798-8242
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121008207Q00000X
OH35-121972207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIL676YMedicare UPIN