Provider Demographics
NPI:1699743187
Name:PAMGANAMAMULA, MADHU (MD)
Entity type:Individual
Prefix:DR
First Name:MADHU
Middle Name:
Last Name:PAMGANAMAMULA
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 3992
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-3992
Mailing Address - Country:US
Mailing Address - Phone:432-582-2446
Mailing Address - Fax:432-582-2960
Practice Address - Street 1:420 E 6TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4529
Practice Address - Country:US
Practice Address - Phone:432-582-2446
Practice Address - Fax:432-582-2960
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX045046201Medicaid
TX8692J1Medicare ID - Type Unspecified
TX045046201Medicaid