Provider Demographics
NPI:1679898829
Name:THANGUDU, PAVAN K (MD)
Entity type:Individual
Prefix:
First Name:PAVAN
Middle Name:K
Last Name:THANGUDU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 SPURS LN
Mailing Address - Street 2:STE 230B
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1671
Mailing Address - Country:US
Mailing Address - Phone:210-690-7400
Mailing Address - Fax:
Practice Address - Street 1:4300 LONDONDERRY RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5317
Practice Address - Country:US
Practice Address - Phone:717-231-8772
Practice Address - Fax:717-231-8435
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD457573207R00000X
TXR1661207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103118689Medicaid
PA505955Medicare PIN