Healthcare Provider Details

I. General information

NPI: 1730395740
Provider Name (Legal Business Name): PREMRAJ MAKKUNI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 EXTON SQUARE MALL
EXTON PA
19341-2440
US

IV. Provider business mailing address

3803 W CHESTER PIKE STE 160
NEWTOWN SQUARE PA
19073-2336
US

V. Phone/Fax

Practice location:
  • Phone: 484-476-1000
  • Fax: 484-876-2164
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD433572
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number57526-020
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier61338
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerDEAN HEALTH INSURANCE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: