Provider Demographics
NPI:1215428784
Name:LAKSHMI K AVALA MD INC
Entity type:Organization
Organization Name:LAKSHMI K AVALA MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAKSHMI
Authorized Official - Middle Name:KUMARI
Authorized Official - Last Name:AVALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-722-4565
Mailing Address - Street 1:5959 GREENBACK LN STE 210
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-4700
Mailing Address - Country:US
Mailing Address - Phone:916-722-4565
Mailing Address - Fax:916-722-5213
Practice Address - Street 1:5959 GREENBACK LN STE 210
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-4700
Practice Address - Country:US
Practice Address - Phone:916-722-4565
Practice Address - Fax:916-722-5213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79103208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA79103OtherCALIFORNIA MEDICAL LICENSE