Provider Demographics
NPI:1932307097
Name:VALLABHANENI, SUNEEL K (MD)
Entity Type:Individual
Prefix:
First Name:SUNEEL
Middle Name:K
Last Name:VALLABHANENI
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-8800
Mailing Address - Fax:
Practice Address - Street 1:425 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1053
Practice Address - Country:US
Practice Address - Phone:512-509-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083452207R00000X
TXQ2497207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700G360210OtherBLUE CARE NETWORK
MI700G360210OtherBLUE CROSS BLUE SHIELD
381870664OtherTAX ID
MI7462944OtherAETNA
MISV083452OtherSTATE LICENSE
MI1932307097Medicaid
MISV083452OtherSTATE LICENSE