Provider Demographics
NPI:1093341059
Name:MUSUNURI, TARAKARAMA DUTT (DO)
Entity Type:Individual
Prefix:
First Name:TARAKARAMA
Middle Name:DUTT
Last Name:MUSUNURI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43187 GALLEGOS AVE APT A
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-5270
Mailing Address - Country:US
Mailing Address - Phone:510-676-3031
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-5270
Practice Address - Country:US
Practice Address - Phone:510-676-3031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206974208D00000X
390200000X
WAOP61460517207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program