Provider Demographics
NPI:1952419004
Name:PONUGOTI, PADMA P (MD)
Entity Type:Individual
Prefix:DR
First Name:PADMA
Middle Name:P
Last Name:PONUGOTI
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 1:76 W SPRINGHILL DR
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-8767
Mailing Address - Country:US
Mailing Address - Phone:812-299-2020
Mailing Address - Fax:819-299-0519
Practice Address - Street 1:76 W SPRINGHILL DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-8767
Practice Address - Country:US
Practice Address - Phone:812-299-2020
Practice Address - Fax:819-299-0519
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049944207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200423530Medicaid
INP00379932Medicare PIN
IN200423530Medicaid