Provider Demographics
NPI:1629086889
Name:PUDUPAKKAM, JAY (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:PUDUPAKKAM
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 1:12221 MERIT DR STE 460
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-2245
Mailing Address - Country:US
Mailing Address - Phone:469-374-3850
Mailing Address - Fax:469-374-3851
Practice Address - Street 1:12221 MERIT DR STE 460
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2245
Practice Address - Country:US
Practice Address - Phone:469-374-3850
Practice Address - Fax:469-374-3851
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4199207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141171205Medicaid
TX8F1689Medicare PIN
TX141171205Medicaid