Healthcare Provider Details

I. General information

NPI: 1124009576
Provider Name (Legal Business Name): LALITHA VALLURI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 SOUTH ST
LAFAYETTE IN
47904-2971
US

IV. Provider business mailing address

2316 SOUTH ST
LAFAYETTE IN
47904-2971
US

V. Phone/Fax

Practice location:
  • Phone: 765-742-1567
  • Fax: 765-742-2750
Mailing address:
  • Phone: 765-742-1567
  • Fax: 765-742-2750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01053607A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: