Healthcare Provider Details

I. General information

NPI: 1053044024
Provider Name (Legal Business Name): POOJITHA PATHAKAMUDI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1398
US

IV. Provider business mailing address

1955 1ST AVE APT 439
NEW YORK NY
10029-6443
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-3600
  • Fax:
Mailing address:
  • Phone: 212-423-6271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34758
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: