Provider Demographics
NPI:1851377477
Name:KURUVILLA, ANITA M (MD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:M
Last Name:KURUVILLA
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 1:310 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3133
Mailing Address - Country:US
Mailing Address - Phone:936-632-8787
Mailing Address - Fax:936-632-8832
Practice Address - Street 1:310 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3133
Practice Address - Country:US
Practice Address - Phone:936-632-8787
Practice Address - Fax:936-632-8832
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL16939207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148180601Medicaid
TX8D1171Medicare ID - Type UnspecifiedMEDICARE ID
TX148180601Medicaid