Provider Demographics
NPI:1801370515
Name:PONNUSWAMY, JEEVANANDAM
Entity Type:Individual
Prefix:
First Name:JEEVANANDAM
Middle Name:
Last Name:PONNUSWAMY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 CEDARBIRD TRL
Mailing Address - Street 2:
Mailing Address - City:MURPHY
Mailing Address - State:TX
Mailing Address - Zip Code:75094-3863
Mailing Address - Country:US
Mailing Address - Phone:972-835-9271
Mailing Address - Fax:
Practice Address - Street 1:1510 N PLANO RD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-2429
Practice Address - Country:US
Practice Address - Phone:972-234-4786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111430225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist