Provider Demographics
NPI:1366402273
Name:PUNUKOLLU, PAVAN KUMAR (MD)
Entity type:Individual
Prefix:
First Name:PAVAN
Middle Name:KUMAR
Last Name:PUNUKOLLU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 CRANBERRY HWY
Mailing Address - Street 2:
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571-1046
Mailing Address - Country:US
Mailing Address - Phone:800-841-5200
Mailing Address - Fax:508-273-1241
Practice Address - Street 1:1 GENERAL ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-2961
Practice Address - Country:US
Practice Address - Phone:978-683-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1302482085R0202X
OH35.0742212085R0202X
MA2690482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000241778OtherANTHEM BCBS
JA839ZOtherMEDICARE PTAN
11286315OtherCAQH
MA110131865AMedicaid
OH300132093OtherRAILROAD MEDICARE
OH2070502Medicaid
OH000000241778OtherANTHEM BCBS