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NPI Code Detail

MEDICARE: PRAVEENA JYOTHINAGARAM MD

MEDICARE: PRAVEENA JYOTHINAGARAM 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
1174400000XSpecialistQ4780TX
2207RN0300XNephrology PhysicianQ4780TX

Other Identifiers

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

General Provider Information

NPI Number : 1306046859
Entity Type Code : Individual
Provider Name (Legal Business Name) : PRAVEENA JYOTHINAGARAM MD
Provider Business Mailing Address
First Line : 1600 WATERS RIDGE DR STE A
Second Line :
City : LEWISVILLE
State : TX
Zip : 75057-6039
Country : US
Telephone Number : 972-219-0558
Fax Number : 214-466-7237
Provider Business Practice Location Address
First Line : 4491 LONG PRAIRIE RD STE 200
Second Line :
City : FLOWER MOUND
State : TX
Zip : 75028-2012
Country : US
Telephone Number : 469-645-0202
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/23/2007
Last Update Date : 08/27/2024

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