Basic Information
| Provider Information | |||||||||
| NPI: | 1154405116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DHARMASHANKAR | ||||||||
| FirstName: | KODLIPET | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DHARMASHANKAR | ||||||||
| OtherFirstName: | KODLIPET | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6807 EMMETT F. LOWRY EXPY | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | TEXAS CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4099455444 | ||||||||
| FaxNumber: | 4099454133 | ||||||||
| Practice Location | |||||||||
| Address1: | 6807 EMMETT F LOWRY EXPY | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | TEXAS CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775912546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4099455444 | ||||||||
| FaxNumber: | 4099454133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 11/16/2016 | ||||||||
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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 | 207R00000X | 45787 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME102151 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | P9324 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | P9324 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 352395301 | 05 | TX | MEDICAID |