Provider Demographics
NPI:1023078250
Name:THANGADA, PRAVEEN KUMAR (MD)
Entity type:Individual
Prefix:DR
First Name:PRAVEEN
Middle Name:KUMAR
Last Name:THANGADA
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 1:115 GALLERY CIR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3389
Mailing Address - Country:US
Mailing Address - Phone:830-303-1819
Mailing Address - Fax:830-379-0816
Practice Address - Street 1:634 E COURT ST
Practice Address - Street 2:STE 102
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-5725
Practice Address - Country:US
Practice Address - Phone:830-303-1819
Practice Address - Fax:830-379-0816
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7226174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099550802Medicaid
TX8F20780Medicare PIN
TXE68726Medicare UPIN