Provider Demographics
NPI:1497788442
Name:PRAMILA, DHAMAVARAPU (MD)
Entity Type:Individual
Prefix:
First Name:DHAMAVARAPU
Middle Name:
Last Name:PRAMILA
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 1:30 PURITAN AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-6029
Mailing Address - Country:US
Mailing Address - Phone:718-263-7970
Mailing Address - Fax:718-250-8864
Practice Address - Street 1:240 WILLOUGHBY ST
Practice Address - Street 2:SUITE 11E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5465
Practice Address - Country:US
Practice Address - Phone:718-250-8866
Practice Address - Fax:718-250-6703
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119606174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00224511Medicaid
NY00224511Medicaid
NY0012GXMedicare PIN
NY625721Medicare PIN