1952355166 NPI number — DR. PREMALATHA VINDHYA M.D.

Table of content: DR. PREMALATHA VINDHYA M.D. (NPI 1952355166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952355166 NPI number — DR. PREMALATHA VINDHYA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VINDHYA
Provider First Name:
PREMALATHA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VINDHYA
Provider Other First Name:
PREMA
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1952355166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 N MIDLAND DR
Provider Second Line Business Mailing Address:
STE 9
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79707-5593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-699-0255
Provider Business Mailing Address Fax Number:
432-520-5914

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2479 E 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79761-4232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-333-1901
Provider Business Practice Location Address Fax Number:
432-520-5914
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  G7739 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 070006346 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 033527501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: N59U . This is a "STATE FARM" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 126180100 . This is a "FIRST CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 820060 . This is a "CENTRAL STATES SOUTHEAST" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 45 21 529 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: G7739 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00G812 . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 72145673 . This is a "WAUSAU" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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