Provider Demographics
NPI:1932246022
Name:KAVITHA SHASHIKUMAR MD PA
Entity Type:Organization
Organization Name:KAVITHA SHASHIKUMAR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:KAVITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHASHIKUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-551-7712
Mailing Address - Street 1:11803 S. FREEWAY
Mailing Address - Street 2:SUITE 213
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115
Mailing Address - Country:US
Mailing Address - Phone:817-551-7712
Mailing Address - Fax:817-551-6262
Practice Address - Street 1:11803 SOUTH FREEWAY
Practice Address - Street 2:SUITE 213
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115
Practice Address - Country:US
Practice Address - Phone:817-551-7712
Practice Address - Fax:817-551-6262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5558207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00495WMedicare ID - Type Unspecified
TXH72665Medicare UPIN