Provider Demographics
NPI:1659377547
Name:PEDDAMATHAM, KUMARA S (MD)
Entity Type:Individual
Prefix:
First Name:KUMARA
Middle Name:S
Last Name:PEDDAMATHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1601 MAIN ST
Mailing Address - Street 2:STE 401
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-3244
Mailing Address - Country:US
Mailing Address - Phone:713-459-4326
Mailing Address - Fax:281-903-5002
Practice Address - Street 1:1601 MAIN ST
Practice Address - Street 2:STE 401
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-3244
Practice Address - Country:US
Practice Address - Phone:281-342-9530
Practice Address - Fax:281-342-9564
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2011-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG4378207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098552503Medicaid
TX00G84FOtherBCBS
TX098552501Medicaid
TX8CM672OtherBCBS
TX8CM672OtherBCBS
TX098552501Medicaid