Healthcare Provider Details

I. General information

NPI: 1528139060
Provider Name (Legal Business Name): MYTHILI PALADUGU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 01/30/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 W TERRELL AVE
FORT WORTH TX
76104-3161
US

IV. Provider business mailing address

PO BOX 33434
FORT WORTH TX
76162-3434
US

V. Phone/Fax

Practice location:
  • Phone: 817-332-8346
  • Fax: 817-332-1723
Mailing address:
  • Phone: 817-332-8346
  • Fax: 817-332-1723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberM6326
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberM6326
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: