1659692606 NPI number — PRADEEP EDUPUGANTI PT

Table of content: PRADEEP EDUPUGANTI PT (NPI 1659692606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659692606 NPI number — PRADEEP EDUPUGANTI PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDUPUGANTI
Provider First Name:
PRADEEP
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1659692606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6420 ESCONDIDO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79912-2977
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-300-1330
Provider Business Mailing Address Fax Number:
915-833-4581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6420 ESCONDIDO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79912-2977
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-300-1330
Provider Business Practice Location Address Fax Number:
915-833-4581
Provider Enumeration Date:
06/14/2010

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: 225100000X , with the licence number:  1196020 , 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: 1196020 . This is a "PHYSICAL THERAPY LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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