Healthcare Provider Details

I. General information

NPI: 1346472230
Provider Name (Legal Business Name): MADHUSUDHANA R MUDDULURU M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 FRANCISCAN DR
BRYAN TX
77802-2544
US

IV. Provider business mailing address

2800 S TEXAS AVE STE 102
BRYAN TX
77802-5361
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-5967
  • Fax: 979-731-5916
Mailing address:
  • Phone: 936-266-3513
  • Fax: 936-266-8618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2012-01567
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57.015930
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberP7316
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2012-01567
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: