Provider Demographics
NPI:1043288574
Name:PONNUSAMY, NARAYANAN (MD)
Entity Type:Individual
Prefix:DR
First Name:NARAYANAN
Middle Name:
Last Name:PONNUSAMY
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 1:604 DEVONWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-4018
Mailing Address - Country:US
Mailing Address - Phone:626-698-6766
Mailing Address - Fax:626-198-1913
Practice Address - Street 1:604 DEVONWOOD RD
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-4018
Practice Address - Country:US
Practice Address - Phone:626-698-6766
Practice Address - Fax:626-198-1913
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52112208600000X
ORMD27193208600000X
WA48033208600000X
NV12604208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0452023Medicare ID - Type Unspecified
CAGK734ZMedicare PIN
A77776Medicare UPIN