Healthcare Provider Details

I. General information

NPI: 1003189440
Provider Name (Legal Business Name): SWETHA PEDAVALLY M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 PELHAM PKWY S BUILDING #1, 3N1
BRONX NY
10461-1138
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 718-918-7460
  • Fax: 718-918-7460
Mailing address:
  • Phone: 402-354-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number29267
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number29267
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: