Healthcare Provider Details

I. General information

NPI: 1538541545
Provider Name (Legal Business Name): MYTHRI KOWLUMANE LAXMINARAYANA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BELLINGER ST
EAU CLAIRE WI
54703-5222
US

IV. Provider business mailing address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

V. Phone/Fax

Practice location:
  • Phone: 715-838-5222
  • Fax:
Mailing address:
  • Phone: 715-838-5222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number66400
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: