Provider Demographics
NPI:1528059672
Name:PONNAIYA, PAUL R (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:PONNAIYA
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 1:3022 S DURANGO DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-4440
Mailing Address - Country:US
Mailing Address - Phone:702-256-3637
Mailing Address - Fax:
Practice Address - Street 1:1795 DR FRANK GASTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1190
Practice Address - Country:US
Practice Address - Phone:702-256-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10806207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1528059672Medicaid
NV1528059672Medicaid