Provider Demographics
NPI:1205819869
Name:BANKULLA, RENUKA (MD)
Entity Type:Individual
Prefix:DR
First Name:RENUKA
Middle Name:
Last Name:BANKULLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:RENUKA
Other - Middle Name:
Other - Last Name:BANKULLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:212 GAIR ST
Mailing Address - Street 2:
Mailing Address - City:PIERMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10968-1058
Mailing Address - Country:US
Mailing Address - Phone:914-434-0329
Mailing Address - Fax:
Practice Address - Street 1:212 GAIR ST
Practice Address - Street 2:
Practice Address - City:PIERMONT
Practice Address - State:NY
Practice Address - Zip Code:10968-1058
Practice Address - Country:US
Practice Address - Phone:914-434-0329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209451207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01801192Medicaid
NY88A61YRXP1Medicare PIN
NY88A61ZXWW1Medicare PIN
NY88A61ZT5H1Medicare PIN
NY0650AFMedicare PIN
NY01801192Medicaid
G65894Medicare UPIN