Provider Demographics
NPI:1255352167
Name:PHANUMAS, DONNA (MD)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:PHANUMAS
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 1:5 PERRYRIDGE RD
Mailing Address - Street 2:CENTER FOR HEALTHY AGING
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-4608
Mailing Address - Country:US
Mailing Address - Phone:203-863-4376
Mailing Address - Fax:203-863-4711
Practice Address - Street 1:5 PERRYRIDGE RD
Practice Address - Street 2:CENTER FOR HEALTHY AGING
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-4608
Practice Address - Country:US
Practice Address - Phone:203-863-4376
Practice Address - Fax:203-863-4711
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038375207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT110007779Medicare ID - Type Unspecified
G94669Medicare UPIN