Healthcare Provider Details

I. General information

NPI: 1700014172
Provider Name (Legal Business Name): SOWMYA A KALLUR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 SW H K DODGEN LOOP
TEMPLE TX
76502-1814
US

IV. Provider business mailing address

PO BOX 844658
DALLAS TX
75284-4658
US

V. Phone/Fax

Practice location:
  • Phone: 254-724-5437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberBP1-0046979
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2011016766
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberQ9838
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: