Basic Information
| Provider Information | |||||||||
| NPI: | 1538480926 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ILLURI | ||||||||
| FirstName: | VIDHYA | ||||||||
| MiddleName: | DEVI SRINIVASAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 87 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782910087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103589172 | ||||||||
| FaxNumber: | 2103589183 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 S ZARZAMORA ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782075209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103587000 | ||||||||
| FaxNumber: | 2103587406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2010 | ||||||||
| LastUpdateDate: | 07/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | Q4604 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.