Healthcare Provider Details

I. General information

NPI: 1205241288
Provider Name (Legal Business Name): NISHANTH REDDY PUNDRU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

125 WHIPPLE ST STE 3
PROVIDENCE RI
02908-3258
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-3985
  • Fax: 401-444-3986
Mailing address:
  • Phone: 401-519-0330
  • Fax: 401-427-7795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD15768
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: