Provider Demographics
NPI:1376848218
Name:BALAKRISHNA REDDY MANGAPURAM INC
Entity Type:Organization
Organization Name:BALAKRISHNA REDDY MANGAPURAM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:TABOADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-364-6677
Mailing Address - Street 1:9004 FOREST XING
Mailing Address - Street 2:SUITE E
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-1197
Mailing Address - Country:US
Mailing Address - Phone:281-364-6677
Mailing Address - Fax:281-292-6379
Practice Address - Street 1:9004 FOREST XING
Practice Address - Street 2:SUITE E
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381-1197
Practice Address - Country:US
Practice Address - Phone:281-364-6677
Practice Address - Fax:281-292-6379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9189207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035975401Medicaid
TX00T29PMedicare PIN
TX035975401Medicaid