Healthcare Provider Details

I. General information

NPI: 1609497387
Provider Name (Legal Business Name): SHANTHINI KUDUVA RAJAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

IV. Provider business mailing address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

V. Phone/Fax

Practice location:
  • Phone: 309-660-2060
  • Fax:
Mailing address:
  • Phone: 817-702-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberU6278
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: