MEDICARE: SUDATH GUNADEERA RANNULU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	P7550	TX
2	208000000X	Pediatrics Physician	249270	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932361078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUDATH GUNADEERA RANNULU M.D.

Provider Business Mailing Address
First Line	:	777 E WHEATLAND RD
Second Line	:	STE 108
City	:	DUNCANVILLE
State	:	TX
Zip	:	75116-4918
Country	:	US
Telephone Number	:	972-293-6300
Fax Number	:	972-293-6301

Provider Business Practice Location Address
First Line	:	4759 SOUTH FWY
Second Line	:	STE 101
City	:	FT WORTH
State	:	TX
Zip	:	76115-3655
Country	:	US
Telephone Number	:	972-293-6300
Fax Number	:	972-293-6301

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2008
Last Update Date	:	03/20/2018

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