Provider Demographics
NPI:1598804171
Name:PANDURANGA, ANANTAPUR (MD)
Entity Type:Individual
Prefix:
First Name:ANANTAPUR
Middle Name:
Last Name:PANDURANGA
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 1:11 QUAIL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GAYLORDSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06755-1203
Mailing Address - Country:US
Mailing Address - Phone:860-354-2436
Mailing Address - Fax:845-877-9702
Practice Address - Street 1:26 CENTER CIR
Practice Address - Street 2:
Practice Address - City:WASSAIC
Practice Address - State:NY
Practice Address - Zip Code:12592-2637
Practice Address - Country:US
Practice Address - Phone:845-877-6821
Practice Address - Fax:845-877-9702
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147572-1208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice