Healthcare Provider Details

I. General information

NPI: 1881452001
Provider Name (Legal Business Name): PALLAVI LAXMI SAMUDRALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALEXANDER T. AUGUSTA MILITARY MEDICAL CENTER 9300 DEWITT LOOP
FORT BELVOIR VA
22060
US

IV. Provider business mailing address

12266 HARBOR TOWN CIR
FAIRFAX VA
22033-2582
US

V. Phone/Fax

Practice location:
  • Phone: 571-231-1803
  • Fax:
Mailing address:
  • Phone: 703-673-8980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: