Provider Demographics
NPI:1417949553
Name:WADERA, PRAMODH KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAMODH
Middle Name:KUMAR
Last Name:WADERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:P
Other - Middle Name:K (BOBBY)
Other - Last Name:WADERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6404
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:281-265-0774
Practice Address - Street 1:1500 CITYWEST BLVD STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-2549
Practice Address - Country:US
Practice Address - Phone:972-233-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073410207L00000X
TXG1575207LP2900X, 208VP0014X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89807BOtherBLUE CROSS BLUE SHIELD
TX136242809Medicaid
TX136242811Medicaid
IL214881OtherMEDICARE GROUP PTAN
TX136242810Medicaid
TX89807BOtherBLUE CROSS BLUE SHIELD
TX136242810Medicaid
TXB27383Medicare UPIN
TX136242809Medicaid