Provider Demographics
NPI:1003893397
Name:SISODIYA, KAMLESH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMLESH
Middle Name:J
Last Name:SISODIYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 GABLES CT STE 201
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-7648
Mailing Address - Country:US
Mailing Address - Phone:469-326-5115
Mailing Address - Fax:469-326-5119
Practice Address - Street 1:5400 STATE HIGHWAY 121 STE 100
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5929
Practice Address - Country:US
Practice Address - Phone:817-479-1500
Practice Address - Fax:817-479-1504
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1931207L00000X, 207LP2900X, 2084P2900X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8EL145OtherBCBS
TXP01356074OtherRR
TX127663610Medicaid
F88548Medicare UPIN
TX340287YK6UMedicare PIN
TX8D3889Medicare PIN
TX127663609Medicaid
TX127663608Medicaid
TX8L4370Medicare PIN