Provider Demographics
NPI:1487184644
Name:SAMUDRALA, PAVANI (MD)
Entity type:Individual
Prefix:MRS
First Name:PAVANI
Middle Name:
Last Name:SAMUDRALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:PAVANI
Other - Middle Name:
Other - Last Name:GOLLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1400 PRESSLER ST. FCT-13 5081
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030
Mailing Address - Country:US
Mailing Address - Phone:832-882-8063
Mailing Address - Fax:
Practice Address - Street 1:707 BERNTER AVENUE
Practice Address - Street 2:MD ANDERSON CANCER CENTER
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-792-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2018-02-21
Deactivation Date:2018-01-25
Deactivation Code:
Reactivation Date:2018-02-21
Provider Licenses
StateLicense IDTaxonomies
TXBP10058872207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine