Provider Demographics
NPI:1083920086
Name:TIRUMANISETTI, PAVANA NAGA GOPI KRISHNA (MD)
Entity Type:Individual
Prefix:
First Name:PAVANA NAGA
Middle Name:GOPI KRISHNA
Last Name:TIRUMANISETTI
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 1:4021 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-2029
Mailing Address - Country:US
Mailing Address - Phone:501-686-5021
Mailing Address - Fax:
Practice Address - Street 1:1601 W 40TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6069
Practice Address - Country:US
Practice Address - Phone:870-541-6000
Practice Address - Fax:870-541-6009
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206188207Q00000X, 208M00000X
ARE-13165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2118013Medicaid
LA2118013Medicaid