Provider Demographics
NPI:1215935010
Name:PANGALLO, FRANK J (MD)
Entity type:Individual
Prefix:DR
First Name:FRANK
Middle Name:J
Last Name:PANGALLO
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 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4335
Mailing Address - Fax:
Practice Address - Street 1:411 W TIPTON ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2363
Practice Address - Country:US
Practice Address - Phone:812-522-2349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067541A207P00000X, 207Q00000X
IL036078511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078511Medicaid
IL04532206OtherBLUE CROSS BLUE SHIELD
ILK10463Medicare PIN
ILK10464Medicare PIN
IL036078511Medicaid
ILD95423Medicare UPIN