Provider Demographics
NPI:1356634950
Name:PANGULUR, PRATHIMA
Entity Type:Individual
Prefix:
First Name:PRATHIMA
Middle Name:
Last Name:PANGULUR
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 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-0553
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3001
Practice Address - Country:US
Practice Address - Phone:585-922-5067
Practice Address - Fax:585-922-1399
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276457207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01131126/RGHMedicaid
NY03001654/NWKMedicaid
NY01131126/RGHMedicaid
NYJ400162450Medicare PIN
NY03001654/NWKMedicaid