Basic Information
| Provider Information | |||||||||
| NPI: | 1710143565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THUMMALAKUNTA | ||||||||
| FirstName: | LAXMI | ||||||||
| MiddleName: | NARASIMHA ABHISHEK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 500 S UNIVERSITY AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016643914 | ||||||||
| FaxNumber: | 5016645246 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S UNIVERSITY AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016643914 | ||||||||
| FaxNumber: | 5016645246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2008 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD440325 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 036131256 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 2085R0202X | E-11339 | AR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207R00000X | 036131256 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036131256 | 05 | IL | MEDICAID |