Provider Demographics
NPI:1104190032
Name:VALLABHANENI, PRIYANKA (MD)
Entity Type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:VALLABHANENI
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 1:1705 E 19TH ST STE 302
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5410
Mailing Address - Country:US
Mailing Address - Phone:918-748-7585
Mailing Address - Fax:918-403-6352
Practice Address - Street 1:1705 E 19TH ST STE 302
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5410
Practice Address - Country:US
Practice Address - Phone:918-748-7585
Practice Address - Fax:918-403-6352
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT200698207R00000X
OK38457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine