Healthcare Provider Details

I. General information

NPI: 1093761553
Provider Name (Legal Business Name): ANUSHA VALLURU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11123 PARKVIEW PLAZA DR SUITE 101
FORT WAYNE IN
46845-1707
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-6650
  • Fax: 260-425-6649
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01062168A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: