Provider Demographics
NPI:1649373614
Name:JOGIMAHANTI, SUDHA R (MD)
Entity type:Individual
Prefix:DR
First Name:SUDHA
Middle Name:R
Last Name:JOGIMAHANTI
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 1:9800 N BEACH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6187
Mailing Address - Country:US
Mailing Address - Phone:817-890-9111
Mailing Address - Fax:866-939-1308
Practice Address - Street 1:9800 N BEACH ST STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6187
Practice Address - Country:US
Practice Address - Phone:817-890-9111
Practice Address - Fax:866-939-1308
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88V704Medicare ID - Type Unspecified
TXG16213Medicare UPIN