Healthcare Provider Details

I. General information

NPI: 1023491255
Provider Name (Legal Business Name): SAI KARAN VAMSI GUDA D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 08/09/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 FAIRMOUNT AVE
FORT WORTH TX
76104-4215
US

IV. Provider business mailing address

1201 FAIRMOUNT AVE
FORT WORTH TX
76104-4215
US

V. Phone/Fax

Practice location:
  • Phone: 817-335-5288
  • Fax: 817-338-0927
Mailing address:
  • Phone: 817-335-5288
  • Fax: 817-338-0927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberT7934
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberT287314
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberT7934
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: