Provider Demographics
NPI:1407843626
Name:VENKAT NAMBURU MD PA
Entity Type:Organization
Organization Name:VENKAT NAMBURU MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VENKAT
Authorized Official - Middle Name:ESWARA-RAO
Authorized Official - Last Name:NAMBURU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-386-5767
Mailing Address - Street 1:7633 BELLAIRE DR S
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4311
Mailing Address - Country:US
Mailing Address - Phone:817-386-5767
Mailing Address - Fax:817-386-5857
Practice Address - Street 1:7633 BELLAIRE DR S
Practice Address - Street 2:SUITE 105
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4311
Practice Address - Country:US
Practice Address - Phone:817-386-5767
Practice Address - Fax:817-386-5857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3766207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181455001Medicaid
TX181455001Medicaid