Provider Demographics
NPI:1790820736
Name:KODITYAL, SANDEEP (MD)
Entity Type:Individual
Prefix:
First Name:SANDEEP
Middle Name:
Last Name:KODITYAL
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 1:22710 PROFESSIONAL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-6009
Mailing Address - Country:US
Mailing Address - Phone:281-358-2850
Mailing Address - Fax:
Practice Address - Street 1:18488 INTERSTATE 45 S
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-4118
Practice Address - Country:US
Practice Address - Phone:281-569-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6990207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187751601Medicaid
TX8J4680Medicare PIN
TX187751601Medicaid