Basic Information
| Provider Information | |||||||||
| NPI: | 1104190032 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALLABHANENI | ||||||||
| FirstName: | PRIYANKA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1705 E 19TH ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187487585 | ||||||||
| FaxNumber: | 9184036352 | ||||||||
| Practice Location | |||||||||
| Address1: | 1705 E 19TH ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187487585 | ||||||||
| FaxNumber: | 9184036352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2012 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MT200698 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 38457 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.