Healthcare Provider Details

I. General information

NPI: 1275897076
Provider Name (Legal Business Name): MADHAVI GAVIRNENI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 MITCHELL BLVD
FT WORTH TX
76105-4642
US

IV. Provider business mailing address

2909 MITCHELL BLVD
FORT WORTH TX
76105-4642
US

V. Phone/Fax

Practice location:
  • Phone: 817-625-4254
  • Fax: 817-740-8612
Mailing address:
  • Phone: 817-625-4254
  • Fax: 817-740-8612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number53236
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ8890
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: