Provider Demographics
NPI:1487663282
Name:PEMMARAJU, SANKAR (DO)
Entity Type:Individual
Prefix:DR
First Name:SANKAR
Middle Name:
Last Name:PEMMARAJU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6904 PETERS PATH
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6655
Mailing Address - Country:US
Mailing Address - Phone:817-488-9874
Mailing Address - Fax:817-488-2865
Practice Address - Street 1:6904 PETERS PATH
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6655
Practice Address - Country:US
Practice Address - Phone:817-488-9874
Practice Address - Fax:817-488-2865
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8811208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0034KAOtherBCBS
TX8K8791OtherBCBS
TX8B3222Medicare PIN
TX0034KAOtherBCBS