Provider Demographics
NPI:1952355166
Name:VINDHYA, PREMALATHA (MD)
Entity Type:Individual
Prefix:DR
First Name:PREMALATHA
Middle Name:
Last Name:VINDHYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PREMA
Other - Middle Name:L
Other - Last Name:VINDHYA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2101 N MIDLAND DR
Mailing Address - Street 2:STE 9
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-5593
Mailing Address - Country:US
Mailing Address - Phone:432-699-0255
Mailing Address - Fax:432-520-5914
Practice Address - Street 1:2479 E 11TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4232
Practice Address - Country:US
Practice Address - Phone:432-333-1901
Practice Address - Fax:432-520-5914
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7739207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX070006346OtherRAILROAD MEDICARE
TX033527501Medicaid
TXN59UOtherSTATE FARM
TX126180100OtherFIRST CARE
TX820060OtherCENTRAL STATES SOUTHEAST
TX45 21 529OtherAETNA
TXG7739OtherSTATE LICENSE
TX00G812OtherBLUE CROSS
TX72145673OtherWAUSAU
TX126180100OtherFIRST CARE
TX00G812Medicare ID - Type Unspecified