Provider Demographics
NPI:1568596963
Name:IYENGAR, RADHA GOPAL (MD)
Entity Type:Individual
Prefix:
First Name:RADHA
Middle Name:GOPAL
Last Name:IYENGAR
Suffix:
Gender:F
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1105 CENTRAL EXPY N STE 2100
Mailing Address - Street 2:MEDICAL BUILDING 2
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6120
Mailing Address - Country:US
Mailing Address - Phone:972-747-6401
Mailing Address - Fax:972-747-6405
Practice Address - Street 1:1105 CENTRAL EXPY N STE 2100
Practice Address - Street 2:MEDICAL BUILDING 2
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6120
Practice Address - Country:US
Practice Address - Phone:972-747-6401
Practice Address - Fax:972-747-6405
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXN1354208600000X, 2086X0206X
GA059085208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206326501Medicaid
TX8F20622Medicare PIN