Provider Demographics
NPI:1497022834
Name:MUDDAMALLE J AUGUSTINE MD PA
Entity Type:Organization
Organization Name:MUDDAMALLE J AUGUSTINE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUDDAMALLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:AUGUSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-861-6464
Mailing Address - Street 1:912 WRIGHT ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-4759
Mailing Address - Country:US
Mailing Address - Phone:817-861-6464
Mailing Address - Fax:817-861-7900
Practice Address - Street 1:912 WRIGHT ST
Practice Address - Street 2:SUITE E
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4759
Practice Address - Country:US
Practice Address - Phone:817-861-6464
Practice Address - Fax:817-861-7900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6261261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
D34183Medicare UPIN