Provider Demographics
NPI:1790717874
Name:BOYAREDDIGARI, SUBRAHMAN R (MD)
Entity Type:Individual
Prefix:
First Name:SUBRAHMAN
Middle Name:R
Last Name:BOYAREDDIGARI
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 1:202 SW 25TH AVE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:MINERAL WELLS
Mailing Address - State:TX
Mailing Address - Zip Code:76067-8298
Mailing Address - Country:US
Mailing Address - Phone:940-328-1771
Mailing Address - Fax:940-325-4440
Practice Address - Street 1:202 SW 25TH AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067-8298
Practice Address - Country:US
Practice Address - Phone:940-328-1771
Practice Address - Fax:940-325-4440
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6476207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1138414-02Medicaid
TX1138414-02Medicaid
TX00FT45Medicare ID - Type Unspecified