Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207K00000X | Allergist & Immunologist | K 3685 | TX |
Y | 207KA0200X | Allergist | K 3685 | TX |
NPI | 1477594836 |
---|---|
Provider Name | Dr. Vasudeva M Bommanna |
First Address | Nacogdoches, TX 75965-1247 |
Second Address | Nacogdoches, TX 75965-1247 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2006 |
Last Update Date | 16/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0020CF | BLUE CROSS # (01) | TX |
612574 | MEDICARE # FOR WEBSTER (01) | TX |
G-59803 | (02) |