Provider Demographics
NPI:1902100217
Name:KUMUDA R PRADHAN MD PA
Entity Type:Organization
Organization Name:KUMUDA R PRADHAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KUMUDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRADHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-779-1716
Mailing Address - Street 1:5959 GATEWAY BLVD W
Mailing Address - Street 2:120
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3331
Mailing Address - Country:US
Mailing Address - Phone:915-774-5557
Mailing Address - Fax:915-771-6496
Practice Address - Street 1:1700 N OREGON ST
Practice Address - Street 2:620
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3584
Practice Address - Country:US
Practice Address - Phone:915-779-1716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5950208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty