Provider Demographics
NPI:1699896704
Name:RAJENDRA K. TANNA, M.D., P.A.
Entity type:Organization
Organization Name:RAJENDRA K. TANNA, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAJENDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:TANNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-336-8855
Mailing Address - Street 1:1000 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3033
Mailing Address - Country:US
Mailing Address - Phone:817-336-8855
Mailing Address - Fax:817-336-4228
Practice Address - Street 1:1000 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3033
Practice Address - Country:US
Practice Address - Phone:817-336-8855
Practice Address - Fax:817-336-4228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7942207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099488101Medicaid
TX00Z624Medicare PIN
TXC22476Medicare UPIN