Provider Demographics
NPI:1982720199
Name:BASAVARAJU, RENUKA VIJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:RENUKA
Middle Name:VIJAY
Last Name:BASAVARAJU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:RENUKA
Other - Middle Name:RAMARAO
Other - Last Name:GHATRAJU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2021 N MACARTHUR BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-2222
Mailing Address - Country:US
Mailing Address - Phone:972-253-2560
Mailing Address - Fax:972-253-4218
Practice Address - Street 1:5350 INDEPENDENCE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-4653
Practice Address - Country:US
Practice Address - Phone:972-253-4370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9020207K00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0475501 04Medicaid
TX0475501 04Medicaid