Provider Demographics
NPI:1578504619
Name:PATHIKONDA, MAYA S (MD)
Entity Type:Individual
Prefix:DR
First Name:MAYA
Middle Name:S
Last Name:PATHIKONDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E AIRLINE RD
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-3926
Mailing Address - Country:US
Mailing Address - Phone:361-575-8500
Mailing Address - Fax:361-575-8416
Practice Address - Street 1:601 E AIRLINE RD
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-3926
Practice Address - Country:US
Practice Address - Phone:361-575-8500
Practice Address - Fax:361-575-8416
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8082208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079684901Medicaid
TX079684902Medicaid
TX118369103Medicaid
TX88070BOtherINDIVIDUAL BCBS
TX742777132OtherTAX ID
TX0039AZOtherGROUP BCBS
TX079684901Medicaid
TX88070BMedicare ID - Type UnspecifiedMEDICARE