Healthcare Provider Details

I. General information

NPI: 1932361078
Provider Name (Legal Business Name): SUDATH GUNADEERA RANNULU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4759 SOUTH FWY STE 101
FT WORTH TX
76115-3655
US

IV. Provider business mailing address

777 E WHEATLAND RD STE 108
DUNCANVILLE TX
75116-4918
US

V. Phone/Fax

Practice location:
  • Phone: 972-293-6300
  • Fax: 972-293-6301
Mailing address:
  • Phone: 972-293-6300
  • Fax: 972-293-6301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP7550
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number249270
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: