Provider Demographics
NPI:1154316537
Name:CHUNDURI, KRISHNABABU (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNABABU
Middle Name:
Last Name:CHUNDURI
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 1:713 GRAINGER STREET
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7400
Mailing Address - Country:US
Mailing Address - Phone:817-336-3968
Mailing Address - Fax:817-336-3917
Practice Address - Street 1:713 GRAINGER STREET
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7400
Practice Address - Country:US
Practice Address - Phone:817-336-3968
Practice Address - Fax:817-336-3917
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG03782084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127931703Medicaid
TXC14487OtherCHAMPUS/TRICARE
TX00TE62OtherBLUE CROSS BLUE SHIELD
TX00TE62Medicare PIN
TX127931703Medicaid