Basic Information
| Provider Information | |||||||||
| NPI: | 1497921829 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANGITAPALLI | ||||||||
| FirstName: | REVATHI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 811 W INTERSTATE 20 | ||||||||
| Address2: | SUITE G14 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760175870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177848268 | ||||||||
| FaxNumber: | 8178048184 | ||||||||
| Practice Location | |||||||||
| Address1: | 811 W INTERSTATE 20 | ||||||||
| Address2: | SUITE G14 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760175870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177848268 | ||||||||
| FaxNumber: | 8178048184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2008 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | M7828 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 204551002 | 05 | TX | MEDICAID | 204551003 | 05 | TX | MEDICAID | 204551004 | 05 | TX | MEDICAID | P01313406 | 01 | TX | MCNT - RAILROAD MEDICARE | OTHER | 204551011 | 01 | TX | MEDICARE RAILROAD | OTHER | M7828 | 01 | TX | PHYSICIAN LICENSE | OTHER |