Provider Demographics
NPI:1851599583
Name:SARDONE-PONNAPPAN, JENNIFER MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:SARDONE-PONNAPPAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MICHELLE
Other - Last Name:PONNAPPAN
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3249 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3429
Mailing Address - Country:US
Mailing Address - Phone:708-783-2486
Mailing Address - Fax:708-783-2452
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:708-783-2486
Practice Address - Fax:708-783-2452
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124549207R00000X
CO45746207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COOHTOOOMedicare UPIN
COC809243Medicare PIN