Provider Demographics
NPI:1144289539
Name:PANCHOLY, AJAY (MD)
Entity type:Individual
Prefix:DR
First Name:AJAY
Middle Name:
Last Name:PANCHOLY
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 1:2330 UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-4817
Mailing Address - Country:US
Mailing Address - Phone:424-290-8004
Mailing Address - Fax:
Practice Address - Street 1:2330 UTAH AVE
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4817
Practice Address - Country:US
Practice Address - Phone:424-290-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME898992085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL118717Medicaid
FL271833200Medicaid
FLP00608665Medicare PIN
FL01558YMedicare PIN
AL118717Medicaid
FL01558Medicare PIN
FL01558UMedicare PIN
FLP00228161Medicare PIN
FLI17772Medicare UPIN
FL271833200Medicaid