Provider Demographics
NPI:1063789154
Name:PANUGANTI, KOTESWARARAO
Entity type:Individual
Prefix:MR
First Name:KOTESWARARAO
Middle Name:
Last Name:PANUGANTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069-6422
Mailing Address - Country:US
Mailing Address - Phone:908-753-1653
Mailing Address - Fax:908-709-0596
Practice Address - Street 1:115 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:WATCHUNG
Practice Address - State:NJ
Practice Address - Zip Code:07069-6422
Practice Address - Country:US
Practice Address - Phone:908-753-1653
Practice Address - Fax:908-709-0596
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02027400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist