Provider Demographics
NPI:1417176629
Name:SUBRAMANIAN, GEETHA (MD)
Entity Type:Individual
Prefix:
First Name:GEETHA
Middle Name:
Last Name:SUBRAMANIAN
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 1:4800 N GALLOWAY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-1176
Mailing Address - Country:US
Mailing Address - Phone:972-270-6368
Mailing Address - Fax:
Practice Address - Street 1:4800 N GALLOWAY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-1176
Practice Address - Country:US
Practice Address - Phone:972-270-6368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7666207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193139601Medicaid
TX8AW050OtherBCBS PROVIDER #
TXTXB115863Medicare PIN
TX193139601Medicaid