Provider Demographics
NPI:1699792564
Name:TALLURI, GAYATHRI (MD)
Entity type:Individual
Prefix:MRS
First Name:GAYATHRI
Middle Name:
Last Name:TALLURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 NORTH CANAL BLVD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301
Mailing Address - Country:US
Mailing Address - Phone:985-446-6381
Mailing Address - Fax:985-446-5992
Practice Address - Street 1:931 NORTH CANAL BLVD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301
Practice Address - Country:US
Practice Address - Phone:985-446-6381
Practice Address - Fax:985-446-5992
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13169R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1557412Medicaid
H02821Medicare UPIN
LA5E800Medicare ID - Type Unspecified