=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437160777
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NACOGDOCHES CARDIAC CENTER, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1023 N MOUND ST SUITE K
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75961-4491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-564-2099
-----------------------------------------------------
Fax | 936-564-2083
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1023 N MOUND ST SUITE K
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75961-4491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-564-2099
-----------------------------------------------------
Fax | 936-564-2083
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | VIJAYA R POKALA
-----------------------------------------------------
Credential | M.D., F.A.C.C.
-----------------------------------------------------
Telephone | 936-564-2099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | H6917
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207UN0901X
-----------------------------------------------------
Taxonomy Name | Nuclear Cardiology Physician
-----------------------------------------------------
License Number | L05982
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------