Provider Demographics
NPI:1366653354
Name:PONNEZHAN, VIMAL J (MD)
Entity Type:Individual
Prefix:DR
First Name:VIMAL
Middle Name:J
Last Name:PONNEZHAN
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 1:3579 E FOOTHILL BLVD STE 432
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3119
Mailing Address - Country:US
Mailing Address - Phone:310-422-3000
Mailing Address - Fax:
Practice Address - Street 1:4081 E OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-3330
Practice Address - Country:US
Practice Address - Phone:323-267-0477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087977207R00000X
CAA116214207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine