Provider Demographics
NPI:1013912856
Name:KAMALI, KAYVAN (MD)
Entity type:Individual
Prefix:
First Name:KAYVAN
Middle Name:
Last Name:KAMALI
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 1:920 JUDSON RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5113
Mailing Address - Country:US
Mailing Address - Phone:903-236-7020
Mailing Address - Fax:903-236-7093
Practice Address - Street 1:920 JUDSON RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5113
Practice Address - Country:US
Practice Address - Phone:903-236-7020
Practice Address - Fax:903-236-7093
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7279207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170428001Medicaid
TXH75825Medicare UPIN
TX170428001Medicaid