Provider Demographics
NPI:1992767693
Name:RENGABHASHYAM, PADMANABHA (MD)
Entity type:Individual
Prefix:
First Name:PADMANABHA
Middle Name:
Last Name:RENGABHASHYAM
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 1:11781 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:SUITE 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3309
Mailing Address - Country:US
Mailing Address - Phone:571-777-5102
Mailing Address - Fax:703-563-6256
Practice Address - Street 1:206 EAST BROWN STREET
Practice Address - Street 2:EAST STROUDSBURG
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3094
Practice Address - Country:US
Practice Address - Phone:570-476-3475
Practice Address - Fax:703-563-6256
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427232207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014272460001Medicaid
I46279Medicare UPIN
PA1014272460001Medicaid