Provider Demographics
NPI:1396351474
Name:MADONDO-GWITIRA, RUDO P
Entity type:Individual
Prefix:
First Name:RUDO
Middle Name:P
Last Name:MADONDO-GWITIRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 W WHEATLAND RD STE 140
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3404
Mailing Address - Country:US
Mailing Address - Phone:972-283-5998
Mailing Address - Fax:
Practice Address - Street 1:3920 W WHEATLAND RD STE 140
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3404
Practice Address - Country:US
Practice Address - Phone:972-283-5998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1014042207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine