Provider Demographics
NPI:1598836116
Name:EZEKIEL, KALAVALLI (MD)
Entity Type:Individual
Prefix:MISS
First Name:KALAVALLI
Middle Name:
Last Name:EZEKIEL
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 1:375 MUNICIPAL DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080
Mailing Address - Country:US
Mailing Address - Phone:972-231-5364
Mailing Address - Fax:972-231-5357
Practice Address - Street 1:375 MUNICIPAL DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080
Practice Address - Country:US
Practice Address - Phone:972-231-5364
Practice Address - Fax:972-231-5357
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6942208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UG42101Medicare UPIN