Healthcare Provider Details

I. General information

NPI: 1417441957
Provider Name (Legal Business Name): RADHA KISHAN ADUSUMILLI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 MEGAN ST
EAGLE PASS TX
78852-5891
US

IV. Provider business mailing address

16620 SAN PEDRO AVE STE 300
SAN ANTONIO TX
78232-2679
US

V. Phone/Fax

Practice location:
  • Phone: 830-773-0212
  • Fax: 830-773-0212
Mailing address:
  • Phone: 210-614-1231
  • Fax: 210-809-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberU1849
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: