Provider Demographics
NPI:1427248962
Name:MUNUSAMY, VENKATARAMAN (MD)
Entity type:Individual
Prefix:DR
First Name:VENKATARAMAN
Middle Name:
Last Name:MUNUSAMY
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 1:200 SOMERSET ST
Mailing Address - Street 2:
Mailing Address - City:MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04462-1258
Mailing Address - Country:US
Mailing Address - Phone:207-723-5161
Mailing Address - Fax:207-723-3040
Practice Address - Street 1:200 SOMERSET ST
Practice Address - Street 2:
Practice Address - City:MILLINOCKET
Practice Address - State:ME
Practice Address - Zip Code:04462-1258
Practice Address - Country:US
Practice Address - Phone:207-723-5161
Practice Address - Fax:207-723-3040
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME018538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME102320000Medicaid
ME12136389OtherCAQH
ME12136389OtherCAQH
200003Medicare PIN