Provider Demographics
NPI:1982207585
Name:GOTTIPATI, KIRAN KUMAR
Entity Type:Individual
Prefix:
First Name:KIRAN
Middle Name:KUMAR
Last Name:GOTTIPATI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10562 DUCKLING DR
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-5896
Mailing Address - Country:US
Mailing Address - Phone:214-620-7222
Mailing Address - Fax:
Practice Address - Street 1:2130 E LEDBETTER DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7435
Practice Address - Country:US
Practice Address - Phone:214-374-3559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist