Provider Demographics
NPI:1013019744
Name:MIRYALA, SHYAMALA (MD)
Entity Type:Individual
Prefix:
First Name:SHYAMALA
Middle Name:
Last Name:MIRYALA
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 1:4400 LONG PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1892
Mailing Address - Country:US
Mailing Address - Phone:469-322-7481
Mailing Address - Fax:469-322-7807
Practice Address - Street 1:4400 LONG PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1892
Practice Address - Country:US
Practice Address - Phone:469-322-7481
Practice Address - Fax:469-322-7807
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101228924208M00000X
TXP4596207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX313368803Medicaid
TX313368804Medicaid
TX266694YKPWMedicare PIN
TX313368803Medicaid
TX266694YKP5Medicare PIN