Provider Demographics
NPI:1003013350
Name:RUPA PACHIGOLLA MD PSC
Entity Type:Organization
Organization Name:RUPA PACHIGOLLA MD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RUPA
Authorized Official - Middle Name:
Authorized Official - Last Name:PACHIGOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-596-8637
Mailing Address - Street 1:2016 FORT WORTH HWY
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-4706
Mailing Address - Country:US
Mailing Address - Phone:817-596-8637
Mailing Address - Fax:817-599-3614
Practice Address - Street 1:2016 FORT WORTH HWY
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-4706
Practice Address - Country:US
Practice Address - Phone:817-596-8637
Practice Address - Fax:817-599-3614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Z738OtherMEDICARE GROUP PIN
TX197261401Medicaid
TX45D1093868OtherCLIA #
1639165731OtherMCRE INDV NPI #
KY38179OtherLICENSE NUMBER
TX1003013350Medicaid
TXN0337OtherTEXAS LICENSE
TX197259801OtherMEDICAID GRP #
KY64071715Medicaid
TX45D1093868OtherCLIA #
TX197261401Medicaid