Provider Demographics
NPI:1700915303
Name:AGUSALA, MADHAVA (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHAVA
Middle Name:
Last Name:AGUSALA
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 1:318 N ALLEGHANEY AVE
Mailing Address - Street 2:SUITE 402
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5052
Mailing Address - Country:US
Mailing Address - Phone:432-337-2714
Mailing Address - Fax:432-337-2726
Practice Address - Street 1:318 N ALLEGHANEY AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5052
Practice Address - Country:US
Practice Address - Phone:432-337-2714
Practice Address - Fax:432-337-2726
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1178207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF08667Medicare UPIN
TX00N21ZMedicare ID - Type Unspecified