Provider Demographics
NPI:1770669624
Name:JYOTHULA, SOMA SUNDARA SHRAVAN KUMA (MD)
Entity Type:Individual
Prefix:
First Name:SOMA
Middle Name:SUNDARA SHRAVAN KUMA
Last Name:JYOTHULA
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 1:7726 LOUIS PASTEUR DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3402
Mailing Address - Country:US
Mailing Address - Phone:210-874-3670
Mailing Address - Fax:210-510-7754
Practice Address - Street 1:7726 LOUIS PASTEUR DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3402
Practice Address - Country:US
Practice Address - Phone:210-874-3670
Practice Address - Fax:210-510-7754
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3108207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2317041OtherLA MEDICAID
TX219528105Medicaid
TX219528104Medicaid
TX1770669624OtherBCBS
TXP01031002OtherRR MEDICARE
TXP00933244Medicare PIN
TXTXB119096Medicare PIN
TXTXB135875Medicare PIN
LA2317041OtherLA MEDICAID
TX219528104Medicaid