Provider Demographics
NPI:1578545620
Name:PANNULLO, AVA M (MD)
Entity Type:Individual
Prefix:DR
First Name:AVA
Middle Name:M
Last Name:PANNULLO
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 1:1 ABRAHMS BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-3949
Mailing Address - Country:US
Mailing Address - Phone:860-523-3854
Mailing Address - Fax:860-523-3828
Practice Address - Street 1:1 ABRAHMS BLVD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-3949
Practice Address - Country:US
Practice Address - Phone:860-523-3800
Practice Address - Fax:860-523-3949
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031669207RG0300X
CT31669207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010031669CT01OtherBC
CT001316696Medicaid
110004291Medicare ID - Type Unspecified
CT001316696Medicaid
CT380000205Medicare PIN