Basic Information
| Provider Information | |||||||||
| NPI: | 1629054317 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOVVALI | ||||||||
| FirstName: | VENKATA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 GASLIGHT BLVD | ||||||||
| Address2: | |||||||||
| City: | LUFKIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759043133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366328787 | ||||||||
| FaxNumber: | 9366328832 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 GASLIGHT BLVD | ||||||||
| Address2: | |||||||||
| City: | LUFKIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759043133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366328787 | ||||||||
| FaxNumber: | 9366328832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 06/08/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | J6148 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 084979601 | 05 | TX | MEDICAID |