Provider Demographics
NPI:1467557124
Name:KOGANTI, MADHURI LATHA (MD)
Entity Type:Individual
Prefix:
First Name:MADHURI
Middle Name:LATHA
Last Name:KOGANTI
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 1:231 W SOUTHLAKE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7037
Mailing Address - Country:US
Mailing Address - Phone:817-865-6280
Mailing Address - Fax:817-865-6287
Practice Address - Street 1:231 W SOUTHLAKE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7037
Practice Address - Country:US
Practice Address - Phone:817-865-6280
Practice Address - Fax:817-865-6287
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP02482084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX288388601Medicaid
TXTXB143506Medicare PIN