Healthcare Provider Details

I. General information

NPI: 1811189269
Provider Name (Legal Business Name): TEJASWI BHARI THIPPESWAMY MD,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W 4TH
COFFEYVILLE KS
67337-3306
US

IV. Provider business mailing address

1910 CUSTOMER CARE WAY
ATWATER CA
95301-5167
US

V. Phone/Fax

Practice location:
  • Phone: 209-383-7441
  • Fax:
Mailing address:
  • Phone: 209-384-6488
  • Fax: 855-202-9336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25886
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE6737
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA132344
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0442440
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: