Provider Demographics
NPI:1396277034
Name:PUNCHAMANNIL, ANJU (DO)
Entity type:Individual
Prefix:DR
First Name:ANJU
Middle Name:
Last Name:PUNCHAMANNIL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25808 86TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-1022
Mailing Address - Country:US
Mailing Address - Phone:347-453-7740
Mailing Address - Fax:
Practice Address - Street 1:25808 86TH AVE
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-1022
Practice Address - Country:US
Practice Address - Phone:347-453-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-31
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY295804208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program