Provider Demographics
NPI:1639876352
Name:KIDANKAL, KIDUS T
Entity Type:Individual
Prefix:
First Name:KIDUS
Middle Name:T
Last Name:KIDANKAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 GATTIS SCHOOL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7472
Mailing Address - Country:US
Mailing Address - Phone:703-459-6629
Mailing Address - Fax:
Practice Address - Street 1:1300 GATTIS SCHOOL RD STE 300
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7472
Practice Address - Country:US
Practice Address - Phone:703-459-6629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47102757343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)