Provider Demographics
NPI:1639306293
Name:BOMMASAMUDRAM, PAVANKUMAR (MD)
Entity type:Individual
Prefix:
First Name:PAVANKUMAR
Middle Name:
Last Name:BOMMASAMUDRAM
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 1:1705 E 19TH ST
Mailing Address - Street 2:STE #302
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104
Mailing Address - Country:US
Mailing Address - Phone:918-748-7585
Mailing Address - Fax:918-748-7539
Practice Address - Street 1:1705 E 19TH ST
Practice Address - Street 2:STE #302
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5405
Practice Address - Country:US
Practice Address - Phone:918-748-7585
Practice Address - Fax:918-748-7539
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27309207R00000X
KS04-41542207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine