Provider Demographics
NPI:1407858426
Name:YEDULAPURAM, MANOHAR (MD)
Entity Type:Individual
Prefix:DR
First Name:MANOHAR
Middle Name:
Last Name:YEDULAPURAM
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:PO BOX 260489
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75026-0489
Mailing Address - Country:US
Mailing Address - Phone:214-842-6449
Mailing Address - Fax:214-975-1460
Practice Address - Street 1:PO BOX 260489
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75026-0489
Practice Address - Country:US
Practice Address - Phone:972-943-9377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1411207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNI14153Medicare UPIN
TX8G9753Medicare PIN
TN3897622Medicare ID - Type Unspecified