Provider Demographics
NPI:1144516212
Name:MESQUITE REGIONAL INTERNAL MEDICINE
Entity type:Organization
Organization Name:MESQUITE REGIONAL INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANURADHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MUNDLURU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-216-0079
Mailing Address - Street 1:929 N GALLOWAY AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-2400
Mailing Address - Country:US
Mailing Address - Phone:972-216-0079
Mailing Address - Fax:
Practice Address - Street 1:929 N GALLOWAY AVE STE 104
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-2400
Practice Address - Country:US
Practice Address - Phone:972-216-0079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-27
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty