Provider Demographics
NPI:1497965677
Name:WUNNAVA, BHANU P (MBBS)
Entity Type:Individual
Prefix:
First Name:BHANU
Middle Name:P
Last Name:WUNNAVA
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4864 JACKSON ST
Mailing Address - Street 2:DEPARTMENT OF FAMILY MEDICINE
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-6400
Mailing Address - Country:US
Mailing Address - Phone:318-330-7661
Mailing Address - Fax:318-330-7648
Practice Address - Street 1:4864 JACKSON ST
Practice Address - Street 2:DEPARTMENT OF FAMILY MEDICINE
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-6400
Practice Address - Country:US
Practice Address - Phone:318-330-7626
Practice Address - Fax:318-330-7648
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA201695207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4N035F600Medicare PIN