Provider Demographics
NPI:1780828772
Name:AMBAVARAM, SUKANYA (MD)
Entity Type:Individual
Prefix:
First Name:SUKANYA
Middle Name:
Last Name:AMBAVARAM
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 1:9719 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-7151
Mailing Address - Country:US
Mailing Address - Phone:214-226-9491
Mailing Address - Fax:
Practice Address - Street 1:2920 N STEMMONS FWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247
Practice Address - Country:US
Practice Address - Phone:214-630-2331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-22
Last Update Date:2019-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN70522083P0500X, 2083P0901X
VA01012425512083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Single Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219946501Medicaid
XB117491Medicare PIN