Provider Demographics
NPI:1922110113
Name:MADHU, PURUSHOTHAMAN (MD)
Entity Type:Individual
Prefix:
First Name:PURUSHOTHAMAN
Middle Name:
Last Name:MADHU
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:PO BOX 99371
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0371
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-1024
Practice Address - Fax:682-885-1033
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXFTL42125208000000X
GA051976208000000X
TXN0935208000000X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA916968941CMedicaid
H82806Medicare UPIN
GA916968941CMedicaid
GA916968941CMedicaid