Provider Demographics
NPI:1962790188
Name:PAMIDIMUKKALA, VAHILA
Entity type:Individual
Prefix:
First Name:VAHILA
Middle Name:
Last Name:PAMIDIMUKKALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 EAST ST
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-4500
Mailing Address - Country:US
Mailing Address - Phone:978-689-4601
Mailing Address - Fax:
Practice Address - Street 1:3400 BAINBRIDGE AVENUE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-6246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA264096207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program