Provider Demographics
NPI:1033566716
Name:KALLURI, LAKSHMI KAVITHA (MBBS)
Entity Type:Individual
Prefix:
First Name:LAKSHMI KAVITHA
Middle Name:
Last Name:KALLURI
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-4804
Mailing Address - Country:US
Mailing Address - Phone:814-889-2011
Mailing Address - Fax:
Practice Address - Street 1:1414 9TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-2415
Practice Address - Country:US
Practice Address - Phone:814-946-1655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2024-03-14
Deactivation Date:2017-01-20
Deactivation Code:
Reactivation Date:2017-04-20
Provider Licenses
StateLicense IDTaxonomies
PAMD477429207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty