Provider Demographics
NPI:1609209949
Name:KALLAM, DEEPTI (MD)
Entity Type:Individual
Prefix:
First Name:DEEPTI
Middle Name:
Last Name:KALLAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BALA DEEPTI
Other - Middle Name:
Other - Last Name:GANGIREDDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3107 W CAMP WISDOM RD STE 110
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-2600
Mailing Address - Country:US
Mailing Address - Phone:214-765-2222
Mailing Address - Fax:214-269-9902
Practice Address - Street 1:3107 W CAMP WISDOM RD STE 110
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-2600
Practice Address - Country:US
Practice Address - Phone:214-765-2222
Practice Address - Fax:214-269-9902
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS1620207RH0003X, 207RX0202X
OH35C00445207RX0202X
OH35C000445207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200122442Medicaid