Provider Demographics
NPI:1215964572
Name:RUMALLA, VISHNU K
Entity type:Individual
Prefix:DR
First Name:VISHNU
Middle Name:K
Last Name:RUMALLA
Suffix:
Gender:M
Credentials:
Other - Prefix:PROF
Other - First Name:TARRANT PLASTIC
Other - Middle Name:
Other - Last Name:SURGERY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1870 KELLER PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3766
Mailing Address - Country:US
Mailing Address - Phone:817-334-0030
Mailing Address - Fax:817-741-6802
Practice Address - Street 1:1870 KELLER PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3766
Practice Address - Country:US
Practice Address - Phone:817-334-0030
Practice Address - Fax:817-741-6802
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8932174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00999WMedicare ID - Type UnspecifiedMEDICARE NUMBER
8C0685Medicare PIN
TXI10242Medicare UPIN