Healthcare Provider Details

I. General information

NPI: 1326453465
Provider Name (Legal Business Name): CEISHA UKATU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12001 SOUTH FWY STE 209
BURLESON TX
76028-7214
US

IV. Provider business mailing address

PO BOX 6278
FORT WORTH TX
76115-0278
US

V. Phone/Fax

Practice location:
  • Phone: 682-385-7010
  • Fax: 682-385-7011
Mailing address:
  • Phone: 682-385-7010
  • Fax: 682-385-7011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2014021212
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036.166777
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberR9879
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: