Basic Information
| Provider Information | |||||||||
| NPI: | 1992090864 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOMULA | ||||||||
| FirstName: | LAKSHMIPATHI | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214341771 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3700 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124857040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2011 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | ME136082 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 01073431A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | NO148 | 01 | FL | FL MEDICARE | OTHER | 109657400 | 05 | FL | MEDICAID |