Healthcare Provider Details

I. General information

NPI: 1083797823
Provider Name (Legal Business Name): NANDAN K PUVVADA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 S LOOP 256 SUITE L
PALESTINE TX
75801-8403
US

IV. Provider business mailing address

4002 S LOOP 256 SUITE L
PALESTINE TX
75801-8403
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 Code208600000X
TaxonomySurgery Physician
License NumberM5002
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: