Provider Demographics
NPI:1851503833
Name:BODDU, LAVANYA (MD)
Entity type:Individual
Prefix:
First Name:LAVANYA
Middle Name:
Last Name:BODDU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 S DENTON TAP RD
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-3207
Mailing Address - Country:US
Mailing Address - Phone:469-312-7777
Mailing Address - Fax:
Practice Address - Street 1:330 S DENTON TAP RD
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-3207
Practice Address - Country:US
Practice Address - Phone:469-312-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-121313207P00000X
IL036121313207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121313OtherBLUE SHIELD
IL036121313-1Medicaid
IL036121313-1Medicaid