Provider Demographics
NPI:1265442602
Name:SUDANAGUNTA, VIJAYA LAKSHMI (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYA
Middle Name:LAKSHMI
Last Name:SUDANAGUNTA
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 1:445 E FM 1382
Mailing Address - Street 2:SUITE 3354
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-6047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 E FM 1382
Practice Address - Street 2:SUITE 3354
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-6047
Practice Address - Country:US
Practice Address - Phone:214-325-1969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0484207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8K9824Medicare PIN
8K9813Medicare PIN
8K9809Medicare PIN
I22798Medicare UPIN