=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518331537
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NALLURI PLASTIC SURGERY AND LASER CENTER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2015
-----------------------------------------------------
Last Update Date | 07/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7300 GIRARD AVE STE 211
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-5138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-299-8999
-----------------------------------------------------
Fax | 858-225-1855
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 258 COAST BLVD
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-299-9999
-----------------------------------------------------
Fax | 858-225-1855
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RAJASEKHAR NALLURI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 858-299-8999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------