Healthcare Provider Details

I. General information

NPI: 1972921054
Provider Name (Legal Business Name): SUKUMAR GANDRA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 8TH AVE
FORT WORTH TX
76110-1812
US

IV. Provider business mailing address

2221 8TH AVE
FORT WORTH TX
76110-1812
US

V. Phone/Fax

Practice location:
  • Phone: 817-336-5060
  • Fax: 817-336-1744
Mailing address:
  • Phone: 817-336-5060
  • Fax: 817-336-1744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33720
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number33720
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberV4911
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: