Provider Demographics
NPI:1356322325
Name:PAUL, PUDICHERY KUNJAVARA (MD)
Entity type:Individual
Prefix:MR
First Name:PUDICHERY
Middle Name:KUNJAVARA
Last Name:PAUL
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 1:705 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-2842
Mailing Address - Country:US
Mailing Address - Phone:352-799-3555
Mailing Address - Fax:352-799-9299
Practice Address - Street 1:705 HARVARD ST
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-2842
Practice Address - Country:US
Practice Address - Phone:352-799-3555
Practice Address - Fax:352-796-9299
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0037402207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065645300Medicaid
26309Medicare ID - Type Unspecified
FL065645300Medicaid