Provider Demographics
NPI:1841398302
Name:MAHADEVAN, DARUKA (MD, PHD)
Entity Type:Individual
Prefix:
First Name:DARUKA
Middle Name:
Last Name:MAHADEVAN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7979 WURZBACH RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4427
Mailing Address - Country:US
Mailing Address - Phone:210-450-1143
Mailing Address - Fax:210-450-0407
Practice Address - Street 1:7979 WURZBACH RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4427
Practice Address - Country:US
Practice Address - Phone:210-450-1143
Practice Address - Fax:210-450-0407
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30621207RH0003X
TXS4811207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX408576301Medicaid
TX408576302OtherCSHCN
AZ721599Medicaid