Provider Demographics
NPI:1043273790
Name:TARAFDAR, KAISER RENI (MD)
Entity Type:Individual
Prefix:
First Name:KAISER
Middle Name:RENI
Last Name:TARAFDAR
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 1:3420 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1314
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:4102 24TH ST
Practice Address - Street 2:STE 409
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1806
Practice Address - Country:US
Practice Address - Phone:806-725-7015
Practice Address - Fax:806-723-6128
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7578207R00000X
NM20020178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154617802Medicaid
H63969Medicare UPIN
TX154617802Medicaid