Healthcare Provider Details

I. General information

NPI: 1063595890
Provider Name (Legal Business Name): LAKSHMI MALATHY PUVVADA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 12/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 S LOOP 256 SUITE L
PALESTINE TX
75801-8491
US

IV. Provider business mailing address

4002 S LOOP 256 SUITE L
PALESTINE TX
75801-8491
US

V. Phone/Fax

Practice location:
  • Phone: 903-723-0033
  • Fax: 903-723-0036
Mailing address:
  • Phone: 903-723-0033
  • Fax: 903-723-0036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberM5001
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: