Provider Demographics
NPI:1306003124
Name:KALLAM, AJAY SHUBHADEEP (MD)
Entity Type:Individual
Prefix:
First Name:AJAY
Middle Name:SHUBHADEEP
Last Name:KALLAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3571 W WHEATLAND RD STE 101
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3461
Mailing Address - Country:US
Mailing Address - Phone:972-274-5555
Mailing Address - Fax:972-274-5663
Practice Address - Street 1:3571 W WHEATLAND RD STE 101
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3461
Practice Address - Country:US
Practice Address - Phone:972-274-5555
Practice Address - Fax:972-274-5663
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6432207RN0300X, 246ZN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZN0300XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherNephrology
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA05919Medicaid