Provider Demographics
NPI:1821075821
Name:THADEPALLI, FERNANDO
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:THADEPALLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12230 LIONESS WAY
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-5603
Mailing Address - Country:US
Mailing Address - Phone:720-644-9355
Mailing Address - Fax:
Practice Address - Street 1:12230 LIONESS WAY
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-5603
Practice Address - Country:US
Practice Address - Phone:720-644-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43458207R00000X
CODR.0059540207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000164657Medicaid