Healthcare Provider Details

I. General information

NPI: 1891750451
Provider Name (Legal Business Name): PRASADVARMA PENMETSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 LONG POND RD
ROCHESTER NY
14626-4117
US

IV. Provider business mailing address

790 LINDEN AVE
ROCHESTER NY
14625-2716
US

V. Phone/Fax

Practice location:
  • Phone: 585-723-0111
  • Fax:
Mailing address:
  • Phone: 585-385-9030
  • Fax: 585-385-9124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number197830
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: