Basic Information
| Provider Information | |||||||||
| NPI: | 1447332457 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANCHAMUKHI | ||||||||
| FirstName: | VARADENDRA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8440 WALNUT HILL LN STE 700 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752313824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143613300 | ||||||||
| FaxNumber: | 2143613353 | ||||||||
| Practice Location | |||||||||
| Address1: | 4510 MEDICAL CENTER DR STE 108 | ||||||||
| Address2: | |||||||||
| City: | MCKINNEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750691624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2147269292 | ||||||||
| FaxNumber: | 2143613431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036-100960 | IL | N | Other Service Providers | Specialist | 207RC0000X | 036100960 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 036100960 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 060070688 | 01 | IL | RAILROAD | OTHER | 036100960 | 05 | IL | MEDICAID |