Healthcare Provider Details

I. General information

NPI: 1013078591
Provider Name (Legal Business Name): TESS SAJU PUNNAPUZHA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2094 PITKIN AVE EAST NEW YORK DIAGNOSTIC & TREATMENT CENTER
BROOKLYN NY
11207-3509
US

IV. Provider business mailing address

1 GATE HOUSE LN
MAMARONECK NY
10543-1012
US

V. Phone/Fax

Practice location:
  • Phone: 718-240-0560
  • Fax:
Mailing address:
  • Phone: 914-833-7823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number201156
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: