Provider Demographics
NPI:1245239433
Name:BHAGAVATHULA, LAKSHMI (MD)
Entity Type:Individual
Prefix:
First Name:LAKSHMI
Middle Name:
Last Name:BHAGAVATHULA
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 1:5730 EXECUTIVE DR STE 230
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1762
Mailing Address - Country:US
Mailing Address - Phone:703-923-4644
Mailing Address - Fax:703-923-4625
Practice Address - Street 1:7440 SPRING VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-4446
Practice Address - Country:US
Practice Address - Phone:703-923-4644
Practice Address - Fax:703-923-4625
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233031207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010201713Medicaid
G02196N01Medicare ID - Type Unspecified
H83770Medicare UPIN