Healthcare Provider Details

I. General information

NPI: 1710515135
Provider Name (Legal Business Name): PRAVEEN ANURADHA WALALIYADDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1448 E CENTER ST STE E
POCATELLO ID
83201-4132
US

IV. Provider business mailing address

1448 E CENTER ST STE E
POCATELLO ID
83201-4132
US

V. Phone/Fax

Practice location:
  • Phone: 208-234-1300
  • Fax:
Mailing address:
  • Phone: 208-234-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberM16603
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberM-16603
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: