MEDICARE: PAVANI MUDDASANI 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	207RG0100X	Gastroenterology Physician	M3657	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

General Provider Information

NPI Number	:	1992781330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAVANI MUDDASANI MD

Provider Business Mailing Address
First Line	:	PO BOX 961205
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76161-1205
Country	:	US
Telephone Number	:	817-740-8400
Fax Number	:	817-377-6553

Provider Business Practice Location Address
First Line	:	508 S ADAMS ST STE 202
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2151
Country	:	US
Telephone Number	:	817-877-3446
Fax Number	:	817-377-6553

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

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	11/03/2020

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Directions to “ PAVANI MUDDASANI MD” Practice Location

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