Provider Demographics
NPI:1679577597
Name:TAMIRISA, PRAVEEN K (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAVEEN
Middle Name:K
Last Name:TAMIRISA
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 1:11803 SOUTH FWY STE 115
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7028
Mailing Address - Country:US
Mailing Address - Phone:817-293-8441
Mailing Address - Fax:817-293-8505
Practice Address - Street 1:11803 SOUTH FWY STE 115
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7028
Practice Address - Country:US
Practice Address - Phone:817-293-8441
Practice Address - Fax:817-293-8505
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077499207RC0000X, 207RI0011X
OH35079630T207RC0000X
TXS2912207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2258971Medicaid
P00711902OtherRRMC
MIMI1635011Medicare PIN
P00711902OtherRRMC
OH4178691Medicare PIN
OHTA4178695Medicare PIN
OH060063854Medicare PIN
OH4053843Medicare PIN
OH4061286Medicare PIN
OH4053847Medicare PIN
OH4053849Medicare PIN
MI23450017Medicare PIN
H40425Medicare UPIN
OH4053846Medicare PIN
MI0N23450Medicare PIN