Provider Demographics
NPI:1205386281
Name:LARAMIE PEDIATRICS/LARAMIE INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:LARAMIE PEDIATRICS/LARAMIE INTERNAL MEDICINE PC
Other - Org Name:DELL RANGE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIJAYA
Authorized Official - Middle Name:MADHAVI
Authorized Official - Last Name:KODURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-365-8789
Mailing Address - Street 1:1252 N. 22ND STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072
Mailing Address - Country:US
Mailing Address - Phone:307-745-3704
Mailing Address - Fax:
Practice Address - Street 1:1252 N. 22ND STREET
Practice Address - Street 2:SUITE B
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072
Practice Address - Country:US
Practice Address - Phone:307-745-3704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LARAMIE PEDIATRICS/LARAMIE INTERNAL MEDICINE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-13
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
WY261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1558672253Medicaid