Provider Demographics
NPI:1649314683
Name:THEKKEKARA, JOSE MATHEW (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:MATHEW
Last Name:THEKKEKARA
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 1:850 HARVARD WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2055
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:85 KIRMAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502
Practice Address - Country:US
Practice Address - Phone:775-982-2826
Practice Address - Fax:775-982-2865
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV89412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1649314683Medicaid
NVP01092343OtherRR MEDICARE PIN
11830250OtherCAQH
NVP01092343OtherRR MEDICARE PIN
NVHO5818Medicare UPIN