Provider Demographics
NPI:1609111699
Name:SHIVAPRASAD, PUNITHA (DO)
Entity Type:Individual
Prefix:DR
First Name:PUNITHA
Middle Name:
Last Name:SHIVAPRASAD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:601 ROUTE 73 N STE 101
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3472
Practice Address - Country:US
Practice Address - Phone:856-237-8045
Practice Address - Fax:856-237-8047
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.145264207RG0100X
NJ25MB09222600207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1609111699OtherHORIZON
NJ1609111699OtherAETNA