Basic Information
| Provider Information | |||||||||
| NPI: | 1134569825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODDHULA | ||||||||
| FirstName: | SOWMYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246400 | ||||||||
| FaxNumber: | 6075476612 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 E MARSHALL AVE STE 1002 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756015660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033154422 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2013 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 288270 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | T1906 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 428571001 | 05 | TX | MEDICAID | 1R9519 | 01 | TX | MEDICARE | OTHER | 8QD098 | 01 | TX | BCBS | OTHER |