Basic Information
| Provider Information | |||||||||
| NPI: | 1811189269 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THIPPESWAMY | ||||||||
| FirstName: | TEJASWI | ||||||||
| MiddleName: | BHARI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1910 CUSTOMER CARE WAY | ||||||||
| Address2: | |||||||||
| City: | ATWATER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953015167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093846488 | ||||||||
| FaxNumber: | 8552029336 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 W 4TH | ||||||||
| Address2: | |||||||||
| City: | COFFEYVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673373306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093837441 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25886 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | E6737 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A132344 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0442440 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5H894 | 01 | AR | BCBS | OTHER | 9186194726 | 01 | OK | UNIVERSITY OF OKLAHOMA | OTHER | E6737 | 01 | AR | STATE LICENSE | OTHER | 189923001 | 05 | AR | MEDICAID |