1891355053 NPI number — DR. LALITH VARDHAN CHOUDHARY NAMBURU MD

Table of content: DR. LALITH VARDHAN CHOUDHARY NAMBURU MD (NPI 1891355053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891355053 NPI number — DR. LALITH VARDHAN CHOUDHARY NAMBURU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NAMBURU
Provider First Name:
LALITH
Provider Middle Name:
VARDHAN CHOUDHARY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1891355053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 70622
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37614-1709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-439-6283
Provider Business Mailing Address Fax Number:
423-439-6283

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N STATE OF FRANKLIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-6035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-431-6111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2019

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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