Healthcare Provider Details

I. General information

NPI: 1306085477
Provider Name (Legal Business Name): PAVAN DEVULAPALLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4511 NW LOOP 410 SUITE 104
SAN ANTONIO TX
78229-5124
US

IV. Provider business mailing address

PO BOX 504152
SAINT LOUIS MO
63150-4152
US

V. Phone/Fax

Practice location:
  • Phone: 210-614-7900
  • Fax: 210-615-1211
Mailing address:
  • Phone: 210-212-8622
  • Fax: 210-212-9197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP9550
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberP9550
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: