Provider Demographics
NPI:1861492480
Name:UP RAO MD PA
Entity Type:Organization
Organization Name:UP RAO MD PA
Other - Org Name:UDIPI PRABHAKAR RAO MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRES. OF THE COMPANY & PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:UDIPI
Authorized Official - Middle Name:PRABHAKAR
Authorized Official - Last Name:RAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-334-0433
Mailing Address - Street 1:500 ADAMS AVE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4656
Mailing Address - Country:US
Mailing Address - Phone:432-334-0433
Mailing Address - Fax:432-334-0414
Practice Address - Street 1:500 ADAMS AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4656
Practice Address - Country:US
Practice Address - Phone:432-334-0433
Practice Address - Fax:432-334-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8631207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0075PZOtherBLUE CROSS BLUESHIELD
TX1103947 02Medicaid
TX00PC60Medicare PIN
TX1103947 02Medicaid