Healthcare Provider Details

I. General information

NPI: 1558287722
Provider Name (Legal Business Name): THEJA REDDY PAKALA MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 07/05/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 S TELSHOR BLVD
LAS CRUCES NM
88011-5069
US

IV. Provider business mailing address

2450 S TELSHOR BLVD
LAS CRUCES NM
88011-5069
US

V. Phone/Fax

Practice location:
  • Phone: 575-556-6489
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2026-0198
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRS2026-0198
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: