Provider Demographics
NPI:1083797823
Name:PUVVADA, NANDAN K (MD)
Entity Type:Individual
Prefix:
First Name:NANDAN
Middle Name:K
Last Name:PUVVADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 S LOOP 256
Mailing Address - Street 2:SUITE L
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-8403
Mailing Address - Country:US
Mailing Address - Phone:903-723-0033
Mailing Address - Fax:903-723-0036
Practice Address - Street 1:4002 S LOOP 256
Practice Address - Street 2:SUITE L
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-8403
Practice Address - Country:US
Practice Address - Phone:903-723-0033
Practice Address - Fax:903-723-0036
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5002208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
351870765OtherTAX ID
F43484Medicare UPIN