MEDICARE: DR. MADHAVI GAVIRNENI M.D.

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	208000000X	Pediatrics Physician	53236	TN
2	208000000X	Pediatrics Physician	Q8890	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3714470	OTHER	TN	GROUP MEDICARE

General Provider Information

NPI Number	:	1275897076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MADHAVI GAVIRNENI M.D.

Provider Business Mailing Address
First Line	:	2909 MITCHELL BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76105-4642
Country	:	US
Telephone Number	:	817-625-4254
Fax Number	:	817-740-8612

Provider Business Practice Location Address
First Line	:	2909 MITCHELL BLVD
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76105-4642
Country	:	US
Telephone Number	:	817-625-4254
Fax Number	:	817-740-8612

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

Provider Enumeration Date	:	06/27/2012
Last Update Date	:	04/16/2025

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