Provider Demographics
NPI:1831759596
Name:PUNJ, MANTAVYA (MD)
Entity type:Individual
Prefix:
First Name:MANTAVYA
Middle Name:
Last Name:PUNJ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-946-4611
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:9605 SANDIFUR PKWY
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-8028
Practice Address - Country:US
Practice Address - Phone:509-942-3170
Practice Address - Fax:509-543-9795
Is Sole Proprietor?:No
Enumeration Date:2019-06-15
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN29309207Q00000X
WAMD61357479207QS1201X, 207Q00000X
FLME154593207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine