Provider Demographics
NPI:1073037461
Name:CHANUMOLU, PRAMODH
Entity Type:Individual
Prefix:
First Name:PRAMODH
Middle Name:
Last Name:CHANUMOLU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 E FOREST ST APT 6
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-2457
Mailing Address - Country:US
Mailing Address - Phone:346-221-2311
Mailing Address - Fax:
Practice Address - Street 1:1468 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6508
Practice Address - Country:US
Practice Address - Phone:212-241-0693
Practice Address - Fax:715-387-5434
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC88829207RN0300X, 207RC0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program