Provider Demographics
NPI:1073838314
Name:KUMARA S. PEDDAMATHAM, MD, PA
Entity Type:Organization
Organization Name:KUMARA S. PEDDAMATHAM, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KUMARA
Authorized Official - Middle Name:S
Authorized Official - Last Name:PEDDAMATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-342-9530
Mailing Address - Street 1:1601 MAIN ST
Mailing Address - Street 2:STE 401
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-3247
Mailing Address - Country:US
Mailing Address - Phone:281-342-9530
Mailing Address - Fax:281-342-9564
Practice Address - Street 1:1601 MAIN ST
Practice Address - Street 2:STE 401
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-3247
Practice Address - Country:US
Practice Address - Phone:281-342-9530
Practice Address - Fax:281-342-9564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-30
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4378207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB103669Medicare PIN