Provider Demographics
NPI:1205847522
Name:POKALA, VIJAYA R (MD, FACC)
Entity Type:Individual
Prefix:
First Name:VIJAYA
Middle Name:R
Last Name:POKALA
Suffix:
Gender:M
Credentials:MD, FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 N MOUND ST
Mailing Address - Street 2:SUITE K
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4491
Mailing Address - Country:US
Mailing Address - Phone:936-564-2099
Mailing Address - Fax:936-564-2083
Practice Address - Street 1:1023 N MOUND ST
Practice Address - Street 2:SUITE K
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4491
Practice Address - Country:US
Practice Address - Phone:936-564-2099
Practice Address - Fax:936-564-2083
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6917207R00000X, 207RI0011X
TXL05982207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179845601Medicaid
TXC0073073OtherCONTROLLED SUBSTANCE REGI
TXH6917OtherPHYSICIAN LICENSE/PERMIT
TXL05982OtherRADIOACTIVE MATERIAL LISC
TXL05982OtherRADIOACTIVE MATERIAL LISC
TX8F2774Medicare ID - Type Unspecified
TXA62184Medicare UPIN