Provider Demographics
NPI:1619374394
Name:DUNCANVILLE CHILDREN'S PEDIATRIC CARE PLLC
Entity Type:Organization
Organization Name:DUNCANVILLE CHILDREN'S PEDIATRIC CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUDATH
Authorized Official - Middle Name:G
Authorized Official - Last Name:RANNULU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-972-3247
Mailing Address - Street 1:777 E WHEATLAND RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-4918
Mailing Address - Country:US
Mailing Address - Phone:917-972-3247
Mailing Address - Fax:917-972-3247
Practice Address - Street 1:777 E WHEATLAND RD
Practice Address - Street 2:SUITE 108
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4918
Practice Address - Country:US
Practice Address - Phone:917-972-3247
Practice Address - Fax:917-972-3247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7550261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty