Provider Demographics
NPI:1669989893
Name:BODDURI, DEVI PRATHYUSHA
Entity type:Individual
Prefix:
First Name:DEVI PRATHYUSHA
Middle Name:
Last Name:BODDURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95113-1231
Mailing Address - Country:US
Mailing Address - Phone:669-208-2155
Mailing Address - Fax:
Practice Address - Street 1:31 N 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95113-1231
Practice Address - Country:US
Practice Address - Phone:669-208-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator