Provider Demographics
NPI:1295174977
Name:THEKKEKANDAM, MARIA (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:THEKKEKANDAM
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:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-339-5413
Mailing Address - Fax:
Practice Address - Street 1:100 VILLAGE CENTER DR STE 1002
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516
Practice Address - Country:US
Practice Address - Phone:984-215-6550
Practice Address - Fax:984-215-6555
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60658356207Q00000X
NC191665207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2061905Medicaid
WA2061905Medicaid