1548574346 NPI number — ABHILASHA RAO PONNAMANENI M.D.

Table of content: ABHILASHA RAO PONNAMANENI M.D. (NPI 1548574346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548574346 NPI number — ABHILASHA RAO PONNAMANENI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PONNAMANENI
Provider First Name:
ABHILASHA
Provider Middle Name:
RAO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548574346
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
811 SUNSET RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08016-3645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-387-9242
Provider Business Mailing Address Fax Number:
609-387-9408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
639 STOKES RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08055-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-654-7556
Provider Business Practice Location Address Fax Number:
609-714-9228
Provider Enumeration Date:
08/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  25MA08964100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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