Provider Demographics
NPI:1548573587
Name:RACHERUVU, MAMATHA (MBBS)
Entity Type:Individual
Prefix:
First Name:MAMATHA
Middle Name:
Last Name:RACHERUVU
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3571W WHEATLAND RD 101
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3461
Mailing Address - Country:US
Mailing Address - Phone:972-274-5555
Mailing Address - Fax:972-274-5663
Practice Address - Street 1:3571 W WHEATLAND RD # 101
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3461
Practice Address - Country:US
Practice Address - Phone:972-274-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXQ3579207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program