Provider Demographics
NPI:1497773303
Name:VALLURU, PARDHA S (MD)
Entity Type:Individual
Prefix:
First Name:PARDHA
Middle Name:S
Last Name:VALLURU
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 1:3720 77TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6630
Mailing Address - Country:US
Mailing Address - Phone:718-505-1952
Mailing Address - Fax:
Practice Address - Street 1:2601 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7745
Practice Address - Country:US
Practice Address - Phone:718-616-4408
Practice Address - Fax:718-616-4105
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203580225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01756032Medicaid
NY01756032Medicaid
NY20Z591Medicare ID - Type Unspecified