Provider Demographics
NPI:1639151947
Name:DAVE, KETAKI B (MD)
Entity Type:Individual
Prefix:DR
First Name:KETAKI
Middle Name:B
Last Name:DAVE
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:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-437-9605
Practice Address - Street 1:3720 S I-35 E
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6857
Practice Address - Country:US
Practice Address - Phone:970-382-1022
Practice Address - Fax:970-380-7947
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1645207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8W1132OtherBLUE CROSS OF TEXAS
TX173620902Medicaid
TX173620903Medicaid
TX173620903Medicaid
TXP00328436Medicare PIN
TX8G7335Medicare PIN