Basic Information
| Provider Information | |||||||||
| NPI: | 1932361078 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANNULU | ||||||||
| FirstName: | SUDATH | ||||||||
| MiddleName: | GUNADEERA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 E WHEATLAND RD | ||||||||
| Address2: | STE 108 | ||||||||
| City: | DUNCANVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751164918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722936300 | ||||||||
| FaxNumber: | 9722936301 | ||||||||
| Practice Location | |||||||||
| Address1: | 4759 SOUTH FWY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | FT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761153655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722936300 | ||||||||
| FaxNumber: | 9722936301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 03/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | P7550 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 249270 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02984105 | 05 | NY | MEDICAID |