Provider Demographics
NPI:1316945645
Name:VALLABHANENI, PURNIMA (MD)
Entity type:Individual
Prefix:DR
First Name:PURNIMA
Middle Name:
Last Name:VALLABHANENI
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 1:32 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:07746-1429
Mailing Address - Country:US
Mailing Address - Phone:732-462-4100
Mailing Address - Fax:732-462-4549
Practice Address - Street 1:3084 STATE ROUTE 27
Practice Address - Street 2:SUITE 1
Practice Address - City:KENDALL PARK
Practice Address - State:NJ
Practice Address - Zip Code:08824-1657
Practice Address - Country:US
Practice Address - Phone:732-821-0873
Practice Address - Fax:732-297-7356
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07524200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9113703Medicaid
H81254Medicare UPIN
068732Q39Medicare ID - Type Unspecified
4848830001Medicare NSC