Provider Demographics
NPI:1083905897
Name:CHERUKURI, PALLAVI
Entity Type:Individual
Prefix:
First Name:PALLAVI
Middle Name:
Last Name:CHERUKURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 RYKOWSKI LN.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-6504
Mailing Address - Country:US
Mailing Address - Phone:845-692-0030
Mailing Address - Fax:
Practice Address - Street 1:707 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2650
Practice Address - Country:US
Practice Address - Phone:845-343-0616
Practice Address - Fax:845-343-0617
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2834712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04775242Medicaid