Provider Demographics
NPI:1710181953
Name:KOYYALAMUDI, PUSHPA LATHA (MD)
Entity Type:Individual
Prefix:
First Name:PUSHPA
Middle Name:LATHA
Last Name:KOYYALAMUDI
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 1:1850 N CENTRAL AVE STE 1600
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4633
Mailing Address - Country:US
Mailing Address - Phone:602-262-8917
Mailing Address - Fax:
Practice Address - Street 1:1850 N CENTRAL AVE STE 1600
Practice Address - Street 2:SUITE 1600
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4633
Practice Address - Country:US
Practice Address - Phone:602-262-8917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96567207L00000X
AZ52085207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279169200Medicaid
FL279169200Medicaid
FLAE314YMedicare PIN