Provider Demographics
NPI:1578533105
Name:MENDIRATTA, ANJU (MD)
Entity Type:Individual
Prefix:MRS
First Name:ANJU
Middle Name:
Last Name:MENDIRATTA
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 1:117 N HICKORY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2424
Mailing Address - Country:US
Mailing Address - Phone:931-646-0880
Mailing Address - Fax:866-834-5618
Practice Address - Street 1:117 N HICKORY AVE STE 200
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2424
Practice Address - Country:US
Practice Address - Phone:931-646-0880
Practice Address - Fax:866-834-5618
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD40111207RN0300X
TN40111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1512941Medicaid
TN33360612Medicare PIN
TNI46749Medicare UPIN