Provider Demographics
NPI:1427078948
Name:PREMKANTH, PHIMAGHAM SRIRAMULU (MD)
Entity type:Individual
Prefix:
First Name:PHIMAGHAM
Middle Name:SRIRAMULU
Last Name:PREMKANTH
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 1:2006 MEADOW RUE CT
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4961
Mailing Address - Country:US
Mailing Address - Phone:727-207-0547
Mailing Address - Fax:727-868-0312
Practice Address - Street 1:12136 COBBLESTONE DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-2432
Practice Address - Country:US
Practice Address - Phone:727-863-5474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89352208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics