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General NPI Number Information
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NPI Number | 1205386281
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Entity Type | Organization
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Legal Business Name | LARAMIE PEDIATRICS/LARAMIE INTERNAL MEDICINE PC
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Dates
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Enumeration Date | 10/13/2016
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Last Update Date | 03/05/2024
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Provider Practice Location Address
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Address Line | 1252 N. 22ND STREET SUITE B
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City | LARAMIE
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State | WY
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Zip | 82072
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Country | US
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Telephone | 307-745-3704
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Fax |
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Provider Business Mailing Address
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Address Line | 1252 N. 22ND STREET SUITE B
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City | LARAMIE
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State | WY
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Zip | 82072
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Country | US
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Telephone | 307-745-3704
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | VIJAYA MADHAVI KODURI
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Credential | M.D
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Telephone | 307-365-8789
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State | WY
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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