Healthcare Provider Details

I. General information

NPI: 1619009172
Provider Name (Legal Business Name): VELLORE KIRUBAKARAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2007
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 W 83RD ST SUITE 254
PRAIRIE VILLAGE KS
66208-5300
US

IV. Provider business mailing address

PO BOX 27127
OVERLAND PARK KS
66225-7127
US

V. Phone/Fax

Practice location:
  • Phone: 913-649-5567
  • Fax: 913-649-7563
Mailing address:
  • Phone: 913-649-5567
  • Fax: 913-649-7563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number04-19582
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35824
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: