Provider Demographics
NPI:1881452001
Name:SAMUDRALA, PALLAVI LAXMI (MD)
Entity type:Individual
Prefix:
First Name:PALLAVI
Middle Name:LAXMI
Last Name:SAMUDRALA
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 1:12266 HARBOR TOWN CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2582
Mailing Address - Country:US
Mailing Address - Phone:703-673-8980
Mailing Address - Fax:
Practice Address - Street 1:ALEXANDER T. AUGUSTA MILITARY MEDICAL CENTER
Practice Address - Street 2:9300 DEWITT LOOP
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060
Practice Address - Country:US
Practice Address - Phone:571-231-1803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider