Provider Demographics
NPI:1255860391
Name:SREEVANI KUNCHAM, MD, PA
Entity Type:Organization
Organization Name:SREEVANI KUNCHAM, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD, PA
Authorized Official - Prefix:DR
Authorized Official - First Name:SREEVANI
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNCHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-436-7424
Mailing Address - Street 1:273 W CHURCH ST., SUITE 100
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057
Mailing Address - Country:US
Mailing Address - Phone:972-436-7424
Mailing Address - Fax:972-219-0343
Practice Address - Street 1:273 W CHURCH ST., SUITE 100
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057
Practice Address - Country:US
Practice Address - Phone:972-436-7424
Practice Address - Fax:972-219-0343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-11
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5423207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1528030210OtherPERSONAL NPI