Basic Information
| Provider Information | |||||||||
| NPI: | 1003893397 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SISODIYA | ||||||||
| FirstName: | KAMLESH | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1417 GABLES CT STE 201 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750757648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4693265115 | ||||||||
| FaxNumber: | 4693265119 | ||||||||
| Practice Location | |||||||||
| Address1: | 5400 STATE HIGHWAY 121 STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLLEYVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760345929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174791500 | ||||||||
| FaxNumber: | 8174791504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | K1931 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | K1931 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 2084P2900X | K1931 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Pain Medicine | 208VP0000X | K1931 | TX | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | K1931 | TX | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8EL145 | 01 | TX | BCBS | OTHER | P01356074 | 01 | TX | RR | OTHER | 127663610 | 05 | TX | MEDICAID |