Provider Demographics
NPI:1063459592
Name:PONNAMBALAM, ANANTHASEKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:ANANTHASEKAR
Middle Name:
Last Name:PONNAMBALAM
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:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-410-5437
Mailing Address - Fax:251-434-3852
Practice Address - Street 1:1601 CENTER STREET
Practice Address - Street 2:SUITE 1S
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-3207
Practice Address - Country:US
Practice Address - Phone:251-410-5437
Practice Address - Fax:251-434-3852
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4244502080P0206X
AL283952080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51545807OtherBCBS-1504 SPRINGHILL
FL280297000Medicaid
AL009913082Medicaid
AL009913083Medicaid
MS07284861Medicaid
AL510I100002Medicare PIN