Basic Information
| Provider Information | |||||||||
| NPI: | 1679898829 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THANGUDU | ||||||||
| FirstName: | PAVAN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 SPURS LN | ||||||||
| Address2: | STE 230B | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782401671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106907400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4300 LONDONDERRY RD | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171095317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172318772 | ||||||||
| FaxNumber: | 7172318435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2010 | ||||||||
| LastUpdateDate: | 08/08/2017 | ||||||||
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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 | 207R00000X | MD457573 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | R1661 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103118689 | 05 | PA | MEDICAID |