Provider Demographics
NPI:1740246065
Name:PANCHAMIRTHAM, KAMALASANI (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMALASANI
Middle Name:
Last Name:PANCHAMIRTHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KAMALA
Other - Middle Name:
Other - Last Name:PANCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1900 27TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-3383
Mailing Address - Country:US
Mailing Address - Phone:772-794-7400
Mailing Address - Fax:772-794-7453
Practice Address - Street 1:1900 27TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3383
Practice Address - Country:US
Practice Address - Phone:772-794-7400
Practice Address - Fax:772-794-7453
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069086208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250905900Medicaid