Healthcare Provider Details

I. General information

NPI: 1205386281
Provider Name (Legal Business Name): LARAMIE PEDIATRICS/LARAMIE INTERNAL MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 03/05/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1252 N. 22ND STREET SUITE B
LARAMIE WY
82072
US

IV. Provider business mailing address

1252 N. 22ND STREET SUITE B
LARAMIE WY
82072
US

V. Phone/Fax

Practice location:
  • Phone: 307-745-3704
  • Fax:
Mailing address:
  • Phone: 307-745-3704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: VIJAYA MADHAVI KODURI
Title or Position: OWNER
Credential: M.D
Phone: 307-365-8789