Provider Demographics
NPI:1477594836
Name:BOMMANNA, VASUDEVA M (MD)
Entity Type:Individual
Prefix:DR
First Name:VASUDEVA
Middle Name:M
Last Name:BOMMANNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 RUSSELL BLVD
Mailing Address - Street 2:SUITE ' B'
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1247
Mailing Address - Country:US
Mailing Address - Phone:936-559-7750
Mailing Address - Fax:936-559-7807
Practice Address - Street 1:607 RUSSELL BLVD
Practice Address - Street 2:SUITE ' B'
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1247
Practice Address - Country:US
Practice Address - Phone:936-559-7750
Practice Address - Fax:936-559-7807
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK 3685207K00000X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX612574OtherMEDICARE # FOR WEBSTER
TX0020CFOtherBLUE CROSS #
TX0020CFMedicare ID - Type UnspecifiedMEDICARE # FOR NACOGDOCHE
TX00340FMedicare ID - Type UnspecifiedMEDICARE # FOR PEARLAND
G-59803Medicare UPIN