Provider Demographics
NPI:1164502423
Name:KALIDAS, MAMTA (MD)
Entity Type:Individual
Prefix:
First Name:MAMTA
Middle Name:
Last Name:KALIDAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12221 N MO PAC EXPY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2401
Mailing Address - Country:US
Mailing Address - Phone:512-901-4008
Mailing Address - Fax:
Practice Address - Street 1:12221 N MO PAC EXPY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2401
Practice Address - Country:US
Practice Address - Phone:512-901-4008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1904207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149156503Medicaid
TX8K1901Medicare PIN
TXP00447159Medicare PIN
H54876Medicare UPIN