Provider Demographics
NPI:1609070325
Name:ELLENDULA, SWATI (MD)
Entity Type:Individual
Prefix:
First Name:SWATI
Middle Name:
Last Name:ELLENDULA
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 1:4500 HILLCREST RD STE 115
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-5418
Mailing Address - Country:US
Mailing Address - Phone:469-213-6400
Mailing Address - Fax:469-213-6473
Practice Address - Street 1:4500 HILLCREST RD STE 115
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-5418
Practice Address - Country:US
Practice Address - Phone:469-213-6400
Practice Address - Fax:469-213-6473
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9542174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX318515YVRJOtherMEDICARE PTAN
TX318515ZH85OtherMEDICARE PTAN