Provider Demographics
NPI:1558564005
Name:RATHNAM, PUNITHA IDA (MD)
Entity Type:Individual
Prefix:
First Name:PUNITHA
Middle Name:IDA
Last Name:RATHNAM
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 1:400 GLENWOOD AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-3870
Mailing Address - Country:US
Mailing Address - Phone:252-686-8091
Mailing Address - Fax:252-686-8092
Practice Address - Street 1:550 W NEW HOPE RD
Practice Address - Street 2:APT A6
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-7560
Practice Address - Country:US
Practice Address - Phone:252-686-8091
Practice Address - Fax:252-686-8092
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2014-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-010452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC160KFOtherBCBSNC
NC5914830Medicaid
NC160KFOtherBCBSNC