Provider Demographics
NPI:1801842919
Name:NEERUKONDA, SAMPATH (MD)
Entity Type:Individual
Prefix:
First Name:SAMPATH
Middle Name:
Last Name:NEERUKONDA
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 1:111 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14903-1303
Mailing Address - Country:US
Mailing Address - Phone:607-734-9539
Mailing Address - Fax:607-734-6293
Practice Address - Street 1:476 CANISTEO ST
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-9768
Practice Address - Country:US
Practice Address - Phone:607-324-3580
Practice Address - Fax:607-324-3998
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193861-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01488462Medicaid
NYRA9065Medicare PIN
NYF05558Medicare UPIN
NY01488462Medicaid