Provider Demographics
NPI:1487773859
Name:NANDAN KUMAR PUVVADA
Entity type:Organization
Organization Name:NANDAN KUMAR PUVVADA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:NANDAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:PUVVADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-723-0033
Mailing Address - Street 1:4002 S LOOP 256
Mailing Address - Street 2:SUITE L
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-8491
Mailing Address - Country:US
Mailing Address - Phone:903-723-0033
Mailing Address - Fax:903-723-0036
Practice Address - Street 1:4002 S LOOP 256
Practice Address - Street 2:SUITE L
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-8491
Practice Address - Country:US
Practice Address - Phone:903-723-0033
Practice Address - Fax:903-723-0036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5002208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF43484Medicare UPIN
TX00X405Medicare PIN