Provider Demographics
NPI:1639188147
Name:RATH, KALYAN KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:KALYAN
Middle Name:KUMAR
Last Name:RATH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1273 S. PEACHTREE ST.
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951
Mailing Address - Country:US
Mailing Address - Phone:409-384-9200
Mailing Address - Fax:409-384-9205
Practice Address - Street 1:1273 S PEACHTREE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951
Practice Address - Country:US
Practice Address - Phone:409-384-9200
Practice Address - Fax:409-384-9205
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1016261QR1300X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121389401Medicaid
TX673913Medicare PIN
TX121389401Medicaid
TXTXB123803Medicare PIN
TX673865Medicare PIN
TX673880Medicare PIN
TX00143LMedicare ID - Type Unspecified