MEDICARE: LAKSHMA R TIYYAGURA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	A56285	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164527883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKSHMA R TIYYAGURA MD

Provider Business Mailing Address
First Line	:	PO BOX 7939
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95267-0939
Country	:	US
Telephone Number	:	209-466-4685
Fax Number	:	204-466-4695

Provider Business Practice Location Address
First Line	:	420 W ACACIA ST
Second Line	:	# 18
City	:	STOCKTON
State	:	CA
Zip	:	95203-2441
Country	:	US
Telephone Number	:	209-466-4685
Fax Number	:	209-466-4695

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	05/11/2009

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