Basic Information
Provider Information | |||||||||
NPI: | 1073784484 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHUNDRU | ||||||||
FirstName: | VITTAL | ||||||||
MiddleName: | KUMAR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6600 S YALE AVE | ||||||||
Address2: | SUITE 1400 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741363347 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184886001 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 800 E DAWSON ST | ||||||||
Address2: |   | ||||||||
City: | TYLER | ||||||||
State: | TX | ||||||||
PostalCode: | 757012036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9036064129 | ||||||||
FaxNumber: | 9036061201 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/13/2008 | ||||||||
LastUpdateDate: | 01/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME101125 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 30627 | OK | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | P3304 | TX | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | P3304 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 281301700 | 05 | FL |   | MEDICAID | 310170108 | 05 | TX |   | MEDICAID |