Provider Demographics
NPI:1235870676
Name:PONNAIYA, SHIRLEY (DO)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:PONNAIYA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HEROES WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2054
Mailing Address - Country:US
Mailing Address - Phone:631-506-4311
Mailing Address - Fax:
Practice Address - Street 1:1 HEROES WAY
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2054
Practice Address - Country:US
Practice Address - Phone:631-506-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY335729207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program