Basic Information
| Provider Information | |||||||||
| NPI: | 1659807774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PONNA | ||||||||
| FirstName: | PRAMOD KUMAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44405 WOODWARD, H-23 | ||||||||
| Address2: | ST. JOSEPH MERCY OAKLAND | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488586233 | ||||||||
| FaxNumber: | 2488583244 | ||||||||
| Practice Location | |||||||||
| Address1: | 44405 WOODWARD, H-23 | ||||||||
| Address2: | ST. JOSEPH MERCY OAKLAND | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488586233 | ||||||||
| FaxNumber: | 2488583244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2017 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/08/2018 | ||||||||
| NPIReactivationDate: | 01/08/2018 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101276921 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.