Provider Demographics
NPI:1619191541
Name:MADHAVA AGUSALA MD.,P.A
Entity Type:Organization
Organization Name:MADHAVA AGUSALA MD.,P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MADHAVA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUSALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-337-2714
Mailing Address - Street 1:318 N ALLEGHANEY AVE
Mailing Address - Street 2:STE 402
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5052
Mailing Address - Country:US
Mailing Address - Phone:432-337-2714
Mailing Address - Fax:432-337-2726
Practice Address - Street 1:318 N ALLEGHANEY AVE
Practice Address - Street 2:STE 402
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5052
Practice Address - Country:US
Practice Address - Phone:432-337-2714
Practice Address - Fax:432-337-2726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3962207QA0505X
TXJ1178207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A3984Medicare PIN