Healthcare Provider Details

I. General information

NPI: 1265228100
Provider Name (Legal Business Name): PRAMOD DAGUPATI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2025
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 SOUTH 40TH STREET OFFICE OF CLINICAL AFFAIRS-S6A EVANS
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

11316 CEDARCLIFFE DR
AUSTIN TX
78750-3609
US

V. Phone/Fax

Practice location:
  • Phone: 215-573-2588
  • Fax:
Mailing address:
  • Phone: 512-979-1720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: