Provider Demographics
NPI:1639121072
Name:VATHADA, MURALI (MD)
Entity Type:Individual
Prefix:
First Name:MURALI
Middle Name:
Last Name:VATHADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E UNIVERSITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6814
Mailing Address - Country:US
Mailing Address - Phone:512-868-1124
Mailing Address - Fax:512-868-9894
Practice Address - Street 1:200 NOLA RUTH BLVD
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-6074
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:254-238-9294
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040270208000000X
TXN5454208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000670271Medicaid
G13636Medicare UPIN