Provider Demographics
NPI:1306085477
Name:DEVULAPALLY, PAVAN (MD)
Entity type:Individual
Prefix:DR
First Name:PAVAN
Middle Name:
Last Name:DEVULAPALLY
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:PO BOX 504152
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4152
Mailing Address - Country:US
Mailing Address - Phone:210-212-8622
Mailing Address - Fax:210-212-9197
Practice Address - Street 1:4511 NW LOOP 410
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5124
Practice Address - Country:US
Practice Address - Phone:210-614-7900
Practice Address - Fax:210-615-1211
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-13
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9550207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX337482901Medicaid
TX353907ZGNNMedicare PIN