Provider Demographics
NPI:1588608103
Name:PONNATHPUR, VIDYA SHANKAR (MD)
Entity Type:Individual
Prefix:
First Name:VIDYA
Middle Name:SHANKAR
Last Name:PONNATHPUR
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 1:239 E BROWN ST
Mailing Address - Street 2:MEDICAL ASSOC OF MONROE COUNTY
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301
Mailing Address - Country:US
Mailing Address - Phone:570-421-3872
Mailing Address - Fax:570-424-6631
Practice Address - Street 1:239 E BROWN ST
Practice Address - Street 2:MEDICAL ASSOC OF MONROE COUNTY
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301
Practice Address - Country:US
Practice Address - Phone:570-421-3872
Practice Address - Fax:570-424-6631
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067991L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPO99417OtherBC
PA0017414180001Medicaid
PAPO99417OtherBC
PA024812ECNMedicare ID - Type Unspecified