Provider Demographics
NPI:1184632309
Name:MANGAPURAM, BALAKRISHNA REDDY (MD)
Entity Type:Individual
Prefix:
First Name:BALAKRISHNA
Middle Name:REDDY
Last Name:MANGAPURAM
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 1:9004 FOREST XING STE E
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-1193
Mailing Address - Country:US
Mailing Address - Phone:281-364-6677
Mailing Address - Fax:281-292-6379
Practice Address - Street 1:9004 FOREST XING STE E
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381-1193
Practice Address - Country:US
Practice Address - Phone:281-364-6677
Practice Address - Fax:281-292-6379
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9189207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG14296Medicare UPIN
TX00T29PMedicare ID - Type Unspecified