Provider Demographics
NPI:1407989742
Name:JAWALEKAR, KSHAMA (MD)
Entity Type:Individual
Prefix:DR
First Name:KSHAMA
Middle Name:
Last Name:JAWALEKAR
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 1:150 E PONCE DE LEON AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2543
Mailing Address - Country:US
Mailing Address - Phone:800-998-5859
Mailing Address - Fax:404-378-7460
Practice Address - Street 1:150 E PONCE DE LEON AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2543
Practice Address - Country:US
Practice Address - Phone:800-998-5859
Practice Address - Fax:404-378-7460
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080163612085R0001X
WV128362085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00817807OtherRAILROAD MEDICARE-CB9013
MO1407989742Medicaid
431560263OtherTRICARE WEST
AR176697001Medicaid
AR176697001Medicaid
431560263OtherTRICARE WEST