MEDICARE: KRISHNABABU CHUNDURI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	G0378	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	C14487	OTHER	TX	CHAMPUS/TRICARE
3	00TE62	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1154316537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISHNABABU CHUNDURI MD

Provider Business Mailing Address
First Line	:	713 GRAINGER STREET
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-7400
Country	:	US
Telephone Number	:	817-336-3968
Fax Number	:	817-336-3917

Provider Business Practice Location Address
First Line	:	713 GRAINGER STREET
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-7400
Country	:	US
Telephone Number	:	817-336-3968
Fax Number	:	817-336-3917

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	10/10/2011

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