Provider Demographics
NPI:1811189269
Name:THIPPESWAMY, TEJASWI BHARI (MD,)
Entity Type:Individual
Prefix:DR
First Name:TEJASWI
Middle Name:BHARI
Last Name:THIPPESWAMY
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 1:1910 CUSTOMER CARE WAY
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-5167
Mailing Address - Country:US
Mailing Address - Phone:209-384-6488
Mailing Address - Fax:855-202-9336
Practice Address - Street 1:1400 W 4TH
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3306
Practice Address - Country:US
Practice Address - Phone:209-383-7441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25886207Q00000X
ARE6737207Q00000X
CAA132344207Q00000X
KS0442440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5H894OtherBCBS
OK9186194726OtherUNIVERSITY OF OKLAHOMA
ARE6737OtherSTATE LICENSE
AR189923001Medicaid
OK9186194726OtherUNIVERSITY OF OKLAHOMA