Provider Demographics
NPI:1487656468
Name:PEDDU, PRASAD K (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASAD
Middle Name:K
Last Name:PEDDU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KOTESWARA
Other - Middle Name:P
Other - Last Name:PEDDU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:515 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3127
Mailing Address - Country:US
Mailing Address - Phone:936-634-3995
Mailing Address - Fax:936-694-4022
Practice Address - Street 1:515 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3127
Practice Address - Country:US
Practice Address - Phone:936-634-3995
Practice Address - Fax:936-634-4022
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110114826OtherMEDICARE RAILROAD ID
TX261887122OtherTAX ID
TX038251701Medicaid
TX261887122OtherTAX ID
TX038251701Medicaid