Provider Demographics
NPI:1326060435
Name:MANDADAPU, SRINIVASA RAO (MD)
Entity Type:Individual
Prefix:
First Name:SRINIVASA
Middle Name:RAO
Last Name:MANDADAPU
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 1:10027 SANDBAR DR
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-5098
Mailing Address - Country:US
Mailing Address - Phone:469-877-8437
Mailing Address - Fax:
Practice Address - Street 1:10027 SANDBAR DR
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-5098
Practice Address - Country:US
Practice Address - Phone:469-877-8437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8121207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164671304Medicaid
TX164671303Medicaid
TX8C6644Medicare ID - Type Unspecified
TX8B7350Medicare ID - Type Unspecified
TXI01680Medicare UPIN