Provider Demographics
NPI:1821073248
Name:SEBASTIAN, KUNJAMMA (MD)
Entity Type:Individual
Prefix:MRS
First Name:KUNJAMMA
Middle Name:
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 AVENUE F N
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77414-3167
Mailing Address - Country:US
Mailing Address - Phone:979-245-2008
Mailing Address - Fax:979-217-8829
Practice Address - Street 1:1410 AVENUE F
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-3418
Practice Address - Country:US
Practice Address - Phone:979-245-1305
Practice Address - Fax:979-244-4442
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1772208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1204703 03Medicaid
TX1204703 03Medicaid