Basic Information
| Provider Information | |||||||||
| NPI: | 1699713198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATIBANDLA | ||||||||
| FirstName: | SUMALATHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9724379605 | ||||||||
| Practice Location | |||||||||
| Address1: | 3070 COLLEGE ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098131686 | ||||||||
| FaxNumber: | 4098133052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | L7102 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | L7102 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 514019YZ21 | 05 | TX | MEDICAID | 159914401 | 05 | TX | MEDICAID | 159914402 | 05 | TX | MEDICAID | 159914403 | 05 | TX | MEDICAID | 8R1522 | 01 | TX | BLUE CROSS OF TEXAS | OTHER |