Basic Information
Provider Information
NPI: 1003003609
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PAKKIVENKATA
FirstName: UMA
MiddleName: B.R.K
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 9900 N CENTRAL EXPY STE 215
Address2:  
City: DALLAS
State: TX
PostalCode: 752310929
CountryCode: US
TelephoneNumber: 2143964950
FaxNumber: 8774235360
Practice Location
Address1: 9900 N CENTRAL EXPY STE 215
Address2:  
City: DALLAS
State: TX
PostalCode: 752310929
CountryCode: US
TelephoneNumber: 2143964950
FaxNumber: 8774235360
Other Information
ProviderEnumerationDate: 09/27/2007
LastUpdateDate: 09/30/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000XN3969TXY Allopathic & Osteopathic PhysiciansInternal Medicine 
207R00000X0101249410VAN Allopathic & Osteopathic PhysiciansInternal Medicine 

ID Information
IDTypeStateIssuerDescription
312707805TX MEDICAID


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