Provider Demographics
NPI:1770542052
Name:DEVABHAKTUNI, PRAMODA KUMARI (MD)
Entity type:Individual
Prefix:MRS
First Name:PRAMODA
Middle Name:KUMARI
Last Name:DEVABHAKTUNI
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 1:18 WOODCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1257
Mailing Address - Country:US
Mailing Address - Phone:304-368-1124
Mailing Address - Fax:304-623-7650
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:LOUIS A. JOHNSON VA MEDICAL CENTER DRIVE
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301
Practice Address - Country:US
Practice Address - Phone:304-623-3461
Practice Address - Fax:304-623-7650
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15671207RG0300X
MS10866207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVVAD 0000Medicare UPIN