Healthcare Provider Details

I. General information

NPI: 1497965677
Provider Name (Legal Business Name): BHANU P WUNNAVA MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4864 JACKSON ST DEPARTMENT OF FAMILY MEDICINE
MONROE LA
71202-6400
US

IV. Provider business mailing address

4864 JACKSON ST DEPARTMENT OF FAMILY MEDICINE
MONROE LA
71202-6400
US

V. Phone/Fax

Practice location:
  • Phone: 318-330-7626
  • Fax: 318-330-7648
Mailing address:
  • Phone: 318-330-7661
  • Fax: 318-330-7648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number201695
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: