1225159510 NPI number — PRASANNA K ATHYALA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225159510 NPI number — PRASANNA K ATHYALA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRASANNA K ATHYALA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225159510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 N JACKSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79761-5124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-333-1837
Provider Business Mailing Address Fax Number:
432-333-1856

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 N JACKSON AVE
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:
79761-5124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-333-1837
Provider Business Practice Location Address Fax Number:
432-333-1856
Provider Enumeration Date:
04/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ATHYALA
Authorized Official First Name:
PRASANNA
Authorized Official Middle Name:
KUMAR
Authorized Official Title or Position:
MEDICAL LABORATORY DIRECTOR
Authorized Official Telephone Number:
432-333-1837

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  45D1020447 , 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)





Copyright © 2007-2025 www.npivalidator.com