Provider Demographics
NPI:1093756439
Name:MUDIPALLI, VASUDEVA RANJIT (MD)
Entity Type:Individual
Prefix:
First Name:VASUDEVA
Middle Name:RANJIT
Last Name:MUDIPALLI
Suffix:
Gender:M
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:PO BOX 780188
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78278-0188
Mailing Address - Country:US
Mailing Address - Phone:830-542-8566
Mailing Address - Fax:210-802-2620
Practice Address - Street 1:11212 TX-151
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251
Practice Address - Country:US
Practice Address - Phone:830-542-8566
Practice Address - Fax:210-802-2620
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9473207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101448658Medicaid
TX2823999Medicaid
PA096322Medicare ID - Type Unspecified
TX2823999Medicaid