Provider Demographics
NPI:1265443493
Name:UNNISSA, IFTHEKAR (MD)
Entity Type:Individual
Prefix:
First Name:IFTHEKAR
Middle Name:
Last Name:UNNISSA
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 1:21372 PROVINCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-7580
Mailing Address - Country:US
Mailing Address - Phone:281-578-9766
Mailing Address - Fax:281-578-6540
Practice Address - Street 1:21372 PROVINCIAL BLVD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-7580
Practice Address - Country:US
Practice Address - Phone:281-578-9766
Practice Address - Fax:281-578-6540
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1416208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0016LGOtherBLUECROSS BLUESHIELD OF TEXAS
TX149703401Medicaid
TX149703403Medicaid
TX149703401Medicaid
E99413Medicare UPIN