Provider Demographics
NPI:1982823985
Name:YETURU, MAMATHA (MD)
Entity Type:Individual
Prefix:
First Name:MAMATHA
Middle Name:
Last Name:YETURU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1991 SPROUL RD
Mailing Address - Street 2:SUITE 625
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3512
Mailing Address - Country:US
Mailing Address - Phone:484-421-1669
Mailing Address - Fax:484-565-8556
Practice Address - Street 1:1991 SPROUL RD
Practice Address - Street 2:SUITE 625
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3512
Practice Address - Country:US
Practice Address - Phone:484-421-1669
Practice Address - Fax:484-565-8556
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD438489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA165698HK1Medicare PIN