Healthcare Provider Details

I. General information

NPI: 1851595441
Provider Name (Legal Business Name): SUDHA SUDHAKAR TALLAVAJHULA MBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 MOURSUND ST
HOUSTON TX
77030-3405
US

IV. Provider business mailing address

6431 FANNIN ST MSB 7.044
HOUSTON TX
77030-1501
US

V. Phone/Fax

Practice location:
  • Phone: 713-797-7742
  • Fax: 713-797-7748
Mailing address:
  • Phone: 713-500-6028
  • Fax: 713-797-7748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberN4777
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License NumberN4777
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License NumberN4777
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberN4777
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: