Basic Information
| Provider Information | |||||||||
| NPI: | 1306003124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALLAM | ||||||||
| FirstName: | AJAY | ||||||||
| MiddleName: | SHUBHADEEP | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3571 W WHEATLAND RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752373461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722745555 | ||||||||
| FaxNumber: | 9722745663 | ||||||||
| Practice Location | |||||||||
| Address1: | 3571 W WHEATLAND RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752373461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722745555 | ||||||||
| FaxNumber: | 9722745663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2008 | ||||||||
| LastUpdateDate: | 06/20/2018 | ||||||||
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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 | 207RN0300X | Q6432 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 05919 | 05 | LA | MEDICAID |