Provider Demographics
NPI:1386639128
Name:ENJETTI, PAMELA (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:
Last Name:ENJETTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 SLATE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-6974
Mailing Address - Country:US
Mailing Address - Phone:276-935-1370
Mailing Address - Fax:276-935-1370
Practice Address - Street 1:1535 SLATE CREEK RD
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6974
Practice Address - Country:US
Practice Address - Phone:276-935-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101041384207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV1431AOtherMEDICARE ID
VA005783429Medicaid
VA050019991OtherRAILROAD MEDICARE
VA054846OtherANTHEM BLUE CROSS
VA0005OtherCAREFIRST BLUE CROSS
VA054846OtherANTHEM BLUE CROSS
VAC02248Medicare PIN
VAVV1431AOtherMEDICARE ID
VA050000510Medicare ID - Type Unspecified