Basic Information
| Provider Information | |||||||||
| NPI: | 1659355824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TEGULAPALLE | ||||||||
| FirstName: | LAKSHMI | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 223 N 1ST AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910067027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6266987246 | ||||||||
| FaxNumber: | 6264471058 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 W CALIFORNIA BLVD | ||||||||
| Address2: | RADIOLOGY DEPT. | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911053010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263975139 | ||||||||
| FaxNumber: | 6264471058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 10/21/2014 | ||||||||
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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 | 2085R0202X | 20A10297 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 20A102970 | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER |