Provider Demographics
NPI:1629171699
Name:NAMBI JOSEPH, PUSHPA (MD)
Entity Type:Individual
Prefix:
First Name:PUSHPA
Middle Name:
Last Name:NAMBI JOSEPH
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 1:5170 US RT 60 EAST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2065
Mailing Address - Country:US
Mailing Address - Phone:304-528-4600
Mailing Address - Fax:304-697-0856
Practice Address - Street 1:5170 US RT 60 EAST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2065
Practice Address - Country:US
Practice Address - Phone:304-528-4600
Practice Address - Fax:304-697-0856
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24655207L00000X, 207LP2900X
WV24510207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810021768Medicaid
WV3810021768Medicaid
WVWV0525AMedicare PIN
OK339-60-0906Medicare ID - Type UnspecifiedMEDICARE NUMBER