Provider Demographics
NPI:1982605887
Name:PUNNAKKATTU, RAJEESH S (MD)
Entity Type:Individual
Prefix:
First Name:RAJEESH
Middle Name:S
Last Name:PUNNAKKATTU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:P
Other - Middle Name:S
Other - Last Name:RAJEESH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1828 E FLORENCE BLVD
Mailing Address - Street 2:STE 112
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-4783
Mailing Address - Country:US
Mailing Address - Phone:520-374-8915
Mailing Address - Fax:520-374-8916
Practice Address - Street 1:1828 E FLORENCE BLVD
Practice Address - Street 2:STE 112
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-4783
Practice Address - Country:US
Practice Address - Phone:520-374-8915
Practice Address - Fax:520-374-8916
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31787207RC0200X, 207RP1001X, 207RS0012X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ875312Medicaid
AZWCSKQOtherSUN HEALTH GROUP #
AZ120730OtherMEDICARE PTAN
AZP00174006OtherRAILROAD MEDICARE
AZZ83652Medicare PIN
AZZ83650Medicare PIN
AZ875312Medicaid