Provider Demographics
NPI:1972532554
Name:PONNURI, JYOTHSNA (MD)
Entity type:Individual
Prefix:
First Name:JYOTHSNA
Middle Name:
Last Name:PONNURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 WINTON ROAD S
Mailing Address - Street 2:JEWISH HOME OF ROCHESTER
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-3957
Mailing Address - Country:US
Mailing Address - Phone:585-784-6400
Mailing Address - Fax:585-341-2370
Practice Address - Street 1:2021 WINTON ROAD S
Practice Address - Street 2:JEWISH HOME OF ROCHESTER
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-3957
Practice Address - Country:US
Practice Address - Phone:585-784-6400
Practice Address - Fax:585-341-2370
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237800207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02708074Medicaid
NYP00388646OtherMEDICARE, RAILROAD
NYRA8551 / 70008A GRPMedicare PIN
NYRA8552 / BA0017Medicare PIN
NYRA8552 / BA0017Medicare PIN
NYRA8551 / 70008A GRPMedicare PIN