Provider Demographics
NPI:1487130696
Name:YELURU, AJITHA
Entity type:Individual
Prefix:
First Name:AJITHA
Middle Name:
Last Name:YELURU
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 1:5 MEDICAL PARK DR STE GL2
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3745
Mailing Address - Country:US
Mailing Address - Phone:501-574-7337
Mailing Address - Fax:
Practice Address - Street 1:5 MEDICAL PARK DR STE GL2
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3745
Practice Address - Country:US
Practice Address - Phone:501-574-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2021-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE-14534208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program