Provider Demographics
NPI:1811881790
Name:GNANASEKARAN, REVATHI (MD)
Entity type:Individual
Prefix:DR
First Name:REVATHI
Middle Name:
Last Name:GNANASEKARAN
Suffix:
Gender:X
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6869 SHADOW GLEN DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-4408
Mailing Address - Country:US
Mailing Address - Phone:972-757-4036
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-5302
Practice Address - Country:US
Practice Address - Phone:409-772-1011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10094056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine