Provider Demographics
NPI:1740279942
Name:PINNAKA, JYOTHISHREE RAO (MD)
Entity type:Individual
Prefix:DR
First Name:JYOTHISHREE
Middle Name:RAO
Last Name:PINNAKA
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 1:53 DANNER CT APT 101
Mailing Address - Street 2:APT # 101
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-5992
Mailing Address - Country:US
Mailing Address - Phone:508-450-6607
Mailing Address - Fax:
Practice Address - Street 1:53 DANNER CT APT 101
Practice Address - Street 2:APT # 101
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-5992
Practice Address - Country:US
Practice Address - Phone:508-450-6607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223154207R00000X
TN48655207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2100096Medicaid
MA2100096Medicaid
A38140Medicare ID - Type Unspecified