Provider Demographics
NPI:1497921829
Name:ANGITAPALLI, REVATHI (MD)
Entity Type:Individual
Prefix:
First Name:REVATHI
Middle Name:
Last Name:ANGITAPALLI
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 1:800 W MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4611
Mailing Address - Country:US
Mailing Address - Phone:817-759-7000
Mailing Address - Fax:817-759-7027
Practice Address - Street 1:515 W MAYFIELD RD STE 102
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2084
Practice Address - Country:US
Practice Address - Phone:817-759-7000
Practice Address - Fax:817-759-7027
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7828207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM7828OtherPHYSICIAN LICENSE
TXM7828OtherPHYSICIAN LICENSE
TX204551004Medicaid
TX204551003Medicaid
TX204551011OtherMEDICARE RAILROAD
TX204551002Medicaid
TX204551011OtherMEDICARE RAILROAD
TX204551002Medicaid
TX8L23737Medicare PIN
TX204551004Medicaid
TX204551003Medicaid