Provider Demographics
NPI:1659807774
Name:PONNA, PRAMOD KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAMOD KUMAR
Middle Name:
Last Name:PONNA
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 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:248-858-3244
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-0000
Practice Address - Fax:318-629-4833
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2023-08-18
Deactivation Date:2018-01-08
Deactivation Code:
Reactivation Date:2018-01-08
Provider Licenses
StateLicense IDTaxonomies
VA0101276921207R00000X
LA324263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine