Provider Demographics
NPI:1023258043
Name:CHENNUPATI, ANUPAMA (MD)
Entity type:Individual
Prefix:DR
First Name:ANUPAMA
Middle Name:
Last Name:CHENNUPATI
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 1:912 CHARLESTON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1536
Mailing Address - Country:US
Mailing Address - Phone:817-818-8433
Mailing Address - Fax:949-404-6343
Practice Address - Street 1:1634 MISTLETOE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4012
Practice Address - Country:US
Practice Address - Phone:817-818-8433
Practice Address - Fax:817-423-7473
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-03
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5523207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024338920001Medicaid
PA1024338920002Medicaid
PA3749707000OtherINDEPENDENCE BLUE CROSS
PA2142845OtherHIGHMARK BCBS
PA3749707000OtherINDEPENDENCE BLUE CROSS