Provider Demographics
NPI:1578739249
Name:MOOKERJEE, SUBHRA JIT (DO)
Entity Type:Individual
Prefix:
First Name:SUBHRA
Middle Name:JIT
Last Name:MOOKERJEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N WASHINGTON AVE STE 7300
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1751
Mailing Address - Country:US
Mailing Address - Phone:214-820-7140
Mailing Address - Fax:214-820-7150
Practice Address - Street 1:411 N WASHINGTON AVE STE 7300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-820-7140
Practice Address - Fax:214-820-7150
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016075208100000X
TXTX17140208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1578739249Medicaid
TX3311201-01Medicaid
MIC36082111Medicare PIN
TX3311201-01Medicaid