Provider Demographics
NPI:1962435628
Name:PUTTA, LAKSHMIDEVI (MD)
Entity type:Individual
Prefix:
First Name:LAKSHMIDEVI
Middle Name:
Last Name:PUTTA
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 1:2625 W ALAMEDA AVE
Mailing Address - Street 2:SUITE#424
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4806
Mailing Address - Country:US
Mailing Address - Phone:818-848-2351
Mailing Address - Fax:818-848-3164
Practice Address - Street 1:2625 W ALAMEDA AVE
Practice Address - Street 2:SUITE#424
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4806
Practice Address - Country:US
Practice Address - Phone:818-848-2351
Practice Address - Fax:818-848-3164
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABP 6350920OtherDEA
CAH24994Medicare UPIN