Provider Demographics
NPI:1689748345
Name:TIKKU, DEEPAK (MD)
Entity Type:Individual
Prefix:
First Name:DEEPAK
Middle Name:
Last Name:TIKKU
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 1:2808 ENTERPRISE RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-2753
Mailing Address - Country:US
Mailing Address - Phone:386-624-6900
Mailing Address - Fax:386-624-6993
Practice Address - Street 1:2808 ENTERPRISE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-2753
Practice Address - Country:US
Practice Address - Phone:386-624-6900
Practice Address - Fax:386-624-6993
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME96609174400000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002197200Medicaid
FL002197200Medicaid