Provider Demographics
NPI:1932437621
Name:PINTO-KINI, PREMILLA DIANA (MD)
Entity Type:Individual
Prefix:
First Name:PREMILLA
Middle Name:DIANA
Last Name:PINTO-KINI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PREMILLA
Other - Middle Name:DIANA
Other - Last Name:PINTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1313 BROADWAY STE 5
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79401-3209
Mailing Address - Country:US
Mailing Address - Phone:806-765-2605
Mailing Address - Fax:806-765-2604
Practice Address - Street 1:1318 BROADWAY
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79401-3206
Practice Address - Country:US
Practice Address - Phone:806-765-2611
Practice Address - Fax:806-687-9894
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX451869Medicaid