Basic Information
Provider Information | |||||||||
NPI: | 1205085651 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PONUGOTI | ||||||||
FirstName: | SHASHANK | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 88 | ||||||||
Address2: |   | ||||||||
City: | WHITE SULPHUR SPRINGS | ||||||||
State: | WV | ||||||||
PostalCode: | 249860088 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045365030 | ||||||||
FaxNumber: | 3045365031 | ||||||||
Practice Location | |||||||||
Address1: | 1 MEDICAL CENTER DRIVE | ||||||||
Address2: |   | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 26505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042931964 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2008 | ||||||||
LastUpdateDate: | 12/14/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 23711 | WV | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000000276995 | 01 | WV | OH UNISON | OTHER | 0817345 | 01 | WV | CIGNA | OTHER | 1072968 | 01 | WV | CARELINK/COVENTRY | OTHER | 613154600 | 01 | WV | BLACK LUNG/FECA | OTHER | 3810015455 | 05 | WV |   | MEDICAID | 7100084200 | 05 | KY |   | MEDICAID | 2969328 | 05 | OH |   | MEDICAID |