Basic Information
| Provider Information | |||||||||
| NPI: | 1063788461 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KADAKIA | ||||||||
| FirstName: | SAMEEP | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B3 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913186 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 4222 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374407876 | ||||||||
| FaxNumber: | 9374407874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 07/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | R0595 | TX | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 35.133158 | OH | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 371152503 | 05 | TX | MEDICAID |