Basic Information
| Provider Information | |||||||||
| NPI: | 1881985588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUDUSSERI | ||||||||
| FirstName: | JERRY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 RIVERSIDE DRIVE | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075845499 | ||||||||
| FaxNumber: | 6075845521 | ||||||||
| Practice Location | |||||||||
| Address1: | 169 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139054246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077987100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2011 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2724241 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 2724241 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.