Healthcare Provider Details

I. General information

NPI: 1982823985
Provider Name (Legal Business Name): MAMATHA YETURU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1991 SPROUL RD SUITE 625
BROOMALL PA
19008-3512
US

IV. Provider business mailing address

1991 SPROUL RD SUITE 625
BROOMALL PA
19008-3512
US

V. Phone/Fax

Practice location:
  • Phone: 484-421-1669
  • Fax: 484-565-8556
Mailing address:
  • Phone: 484-421-1669
  • Fax: 484-565-8556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD438489
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: