Provider Demographics
NPI:1255539086
Name:GILLALA, MEGHANA R (MD)
Entity type:Individual
Prefix:
First Name:MEGHANA
Middle Name:R
Last Name:GILLALA
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:PO BOX 2129
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-2129
Mailing Address - Country:US
Mailing Address - Phone:432-640-2401
Mailing Address - Fax:432-640-1118
Practice Address - Street 1:500 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5001
Practice Address - Country:US
Practice Address - Phone:432-640-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5603207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J9443Medicare PIN