Provider Demographics
NPI:1457360653
Name:PONNAPALLI, SARMA V (MD)
Entity Type:Individual
Prefix:DR
First Name:SARMA
Middle Name:V
Last Name:PONNAPALLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 QUEENS BLVD APT 4E
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5586
Mailing Address - Country:US
Mailing Address - Phone:347-392-4210
Mailing Address - Fax:
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:WOODHULL HOSPITAL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5317
Practice Address - Country:US
Practice Address - Phone:719-963-8782
Practice Address - Fax:718-963-8784
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00589762Medicaid
NV48A101Medicare ID - Type Unspecified
NY00589762Medicaid