1023258043 NPI number — DR. ANUPAMA CHENNUPATI MD

Table of content: DR. ANUPAMA CHENNUPATI MD (NPI 1023258043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023258043 NPI number — DR. ANUPAMA CHENNUPATI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHENNUPATI
Provider First Name:
ANUPAMA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023258043
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
912 CHARLESTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-1536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-818-8433
Provider Business Mailing Address Fax Number:
949-404-6343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11803 SOUTH FWY STE 215
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLESON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76028-7030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-818-8433
Provider Business Practice Location Address Fax Number:
949-404-6343
Provider Enumeration Date:
03/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  P5523 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1024338920001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1024338920002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3749707000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2142845 . This is a "HIGHMARK BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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