Provider Demographics
NPI:1376974345
Name:DEEPIKA KILARU MD PA
Entity Type:Organization
Organization Name:DEEPIKA KILARU MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEEPKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KILARU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-455-0579
Mailing Address - Street 1:2600 E SOUTHLAKE BLVD STE 120332
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6634
Mailing Address - Country:US
Mailing Address - Phone:214-455-0579
Mailing Address - Fax:
Practice Address - Street 1:4100 HERITAGE AVE STE 106
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-5716
Practice Address - Country:US
Practice Address - Phone:214-455-0579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1365207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX334393YX5QMedicare PIN