Provider Demographics
NPI:1912904491
Name:MUNDLURU, GIRI D (MD)
Entity Type:Individual
Prefix:DR
First Name:GIRI
Middle Name:D
Last Name:MUNDLURU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:844 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2223
Mailing Address - Country:US
Mailing Address - Phone:817-336-4278
Mailing Address - Fax:817-335-1650
Practice Address - Street 1:844 PENNSYLVANIA AVE
Practice Address - Street 2:STE 110
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2223
Practice Address - Country:US
Practice Address - Phone:817-336-4278
Practice Address - Fax:817-335-1650
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH4026207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146634401Medicaid
TXE04439Medicare UPIN
TX86180YOtherINDIVIDUAL BLUE CROSS NUM
TXE04439Medicare UPIN