Provider Demographics
NPI:1326257163
Name:MANTHENA, GEETA (MD)
Entity Type:Individual
Prefix:
First Name:GEETA
Middle Name:
Last Name:MANTHENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9202 ELAM RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75217-4151
Mailing Address - Country:US
Mailing Address - Phone:214-786-6968
Mailing Address - Fax:
Practice Address - Street 1:1500 S. MAIN STREET
Practice Address - Street 2:
Practice Address - City:FORTWORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:862-220-0328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN6918207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program