Provider Demographics
NPI:1588168157
Name:BONDUGULA, MANITH
Entity type:Individual
Prefix:DR
First Name:MANITH
Middle Name:
Last Name:BONDUGULA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CANNON ST.
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-725-7900
Mailing Address - Fax:682-207-1030
Practice Address - Street 1:1001 12TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3926
Practice Address - Country:US
Practice Address - Phone:817-725-7880
Practice Address - Fax:817-447-7110
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47326207R00000X
TXT4126207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine