Healthcare Provider Details

I. General information

NPI: 1568877934
Provider Name (Legal Business Name): SUMANT PONNALA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 01/18/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2734 EL CAMINO REAL
SANTA CLARA CA
95051-3007
US

IV. Provider business mailing address

2350 W EL CAMINO REAL FL 2
MOUNTAIN VIEW CA
94040-6203
US

V. Phone/Fax

Practice location:
  • Phone: 408-241-3801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6891
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A15611
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: