Provider Demographics
NPI:1659318038
Name:REDDY, RAGHURAM M (MD)
Entity Type:Individual
Prefix:
First Name:RAGHURAM
Middle Name:M
Last Name:REDDY
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 1:1845 PRECINCT LINE RD STE 209
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3109
Mailing Address - Country:US
Mailing Address - Phone:817-336-4638
Mailing Address - Fax:817-336-7637
Practice Address - Street 1:1845 PRECINCT LINE RD STE 209
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3109
Practice Address - Country:US
Practice Address - Phone:817-336-4638
Practice Address - Fax:817-336-7637
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001019912085R0202X
OK211712085R0202X
TXM44682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1659318038Medicaid
TXP00379525OtherRR MEDICARE
TXP00379525OtherRR MEDICARE
TX1659318038Medicaid