Provider Demographics
NPI:1932361078
Name:RANNULU, SUDATH GUNADEERA (MD)
Entity type:Individual
Prefix:
First Name:SUDATH
Middle Name:GUNADEERA
Last Name:RANNULU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:777 E WHEATLAND RD
Mailing Address - Street 2:STE 108
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-4918
Mailing Address - Country:US
Mailing Address - Phone:972-293-6300
Mailing Address - Fax:972-293-6301
Practice Address - Street 1:4759 SOUTH FWY
Practice Address - Street 2:STE 101
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-3655
Practice Address - Country:US
Practice Address - Phone:972-293-6300
Practice Address - Fax:972-293-6301
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7550208000000X
NY249270208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02984105Medicaid
NY02984105Medicaid