Provider Demographics
NPI:1720138829
Name:ADUSUMALLI, JASVANT (MD)
Entity type:Individual
Prefix:
First Name:JASVANT
Middle Name:
Last Name:ADUSUMALLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12200 RENFERT WAY STE G-3
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5654
Mailing Address - Country:US
Mailing Address - Phone:512-821-2540
Mailing Address - Fax:512-973-3533
Practice Address - Street 1:1583 E COMMON ST STE 111
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-3174
Practice Address - Country:US
Practice Address - Phone:830-629-2826
Practice Address - Fax:830-629-2841
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2820207V00000X, 207VM0101X
GA052873207V00000X
CAA86507207VM0101X
AZ36618207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ224465Medicaid
TXTXB158563Medicare PIN