Provider Demographics
NPI:1851957526
Name:PANCHATSHARAM, PRANAV KUMAR (DO)
Entity type:Individual
Prefix:DR
First Name:PRANAV
Middle Name:KUMAR
Last Name:PANCHATSHARAM
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-458-3410
Mailing Address - Fax:260-425-2881
Practice Address - Street 1:800 BROADWAY STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2149
Practice Address - Country:US
Practice Address - Phone:260-458-3410
Practice Address - Fax:260-425-2881
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2024-10-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN02007800A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology