Provider Demographics
NPI:1073987533
Name:LUNG CLINIC PLLC
Entity Type:Organization
Organization Name:LUNG CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ABHISHEK
Authorized Official - Middle Name:
Authorized Official - Last Name:VEDAVALLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-718-7494
Mailing Address - Street 1:PO BOX 733537
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3537
Mailing Address - Country:US
Mailing Address - Phone:210-774-5443
Mailing Address - Fax:336-350-8495
Practice Address - Street 1:555 CREEKSIDE XING
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130
Practice Address - Country:US
Practice Address - Phone:210-774-5443
Practice Address - Fax:336-350-8495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-20
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP6293207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3642415-01Medicaid