Provider Demographics
NPI:1962819771
Name:PAI BANTWAL HEBBALASANKATTE, POONAM (MD)
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:PAI BANTWAL HEBBALASANKATTE
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:PO BOX 5024
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-5024
Mailing Address - Country:US
Mailing Address - Phone:412-937-5937
Mailing Address - Fax:843-806-4742
Practice Address - Street 1:1000 10TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1147
Practice Address - Country:US
Practice Address - Phone:412-937-5937
Practice Address - Fax:843-806-4742
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY293650207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program