Provider Demographics
NPI:1972891737
Name:PODUGU, AMARESHWAR (MD)
Entity type:Individual
Prefix:
First Name:AMARESHWAR
Middle Name:
Last Name:PODUGU
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 1:2726 FULTON DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3506
Mailing Address - Country:US
Mailing Address - Phone:330-455-5011
Mailing Address - Fax:
Practice Address - Street 1:2726 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3506
Practice Address - Country:US
Practice Address - Phone:330-455-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-130380207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0236878Medicaid