Healthcare Provider Details

I. General information

NPI: 1215518816
Provider Name (Legal Business Name): JEFF JOE THEKKEKARA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 E DEVONSHIRE AVE
HEMET CA
92543-3083
US

IV. Provider business mailing address

2305 BUCKEYE DR
MESQUITE TX
75181-1074
US

V. Phone/Fax

Practice location:
  • Phone: 951-652-2811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: