Healthcare Provider Details

I. General information

NPI: 1013478668
Provider Name (Legal Business Name): PAVANKUMAR THOTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 07/10/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

IV. Provider business mailing address

4301 TULANE AVE APT 366
NEW ORLEANS LA
70119-6761
US

V. Phone/Fax

Practice location:
  • Phone: 866-624-7637
  • Fax:
Mailing address:
  • Phone: 940-704-8096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number331480
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: