Provider Demographics
NPI:1164418075
Name:PUVVALA, SUKUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SUKUMAR
Middle Name:
Last Name:PUVVALA
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 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-812-4083
Mailing Address - Fax:717-812-2244
Practice Address - Street 1:35 MONUMENT RD
Practice Address - Street 2:SUITE 201
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5074
Practice Address - Country:US
Practice Address - Phone:717-812-4083
Practice Address - Fax:717-812-2244
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4215192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001958935Medicaid
MD402022700Medicaid
PA7581465OtherAETNA
PA50074893OtherCAPITAL BLUE CROSS WMG
MD919374OtherCAREFIRST MD BCBS
PA235944OtherUNISON-WMG
PA1468864OtherHIGHMARK BLUE SHIELD
PA1530454OtherGATEWAY-WMG
PA2006917OtherAMERIHEALTH MERCY WMG
PA212042OtherJOHN HOPKINS
PA1468864OtherHIGHMARK BLUE SHIELD
PA1530454OtherGATEWAY-WMG
PAP00675739Medicare PIN