Basic Information
| Provider Information | |||||||||
| NPI: | 1255301701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANOZZO | ||||||||
| FirstName: | SHASHI | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PANOZZO | ||||||||
| OtherFirstName: | SHASHI | ||||||||
| OtherMiddleName: | K. | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 GANNETT DR STE C | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041065900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078280361 | ||||||||
| FaxNumber: | 2078741483 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | YARMOUTH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040966723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078469013 | ||||||||
| FaxNumber: | 2075238586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD18259 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.