Healthcare Provider Details

I. General information

NPI: 1720304298
Provider Name (Legal Business Name): KUMARAN MUDALIAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 NORTH BECKLEY AVE PATHOLOGY DEPARTMENT
DALLAS TX
75203-1201
US

IV. Provider business mailing address

1441 NORTH BECKLEY AVE PATHOLOGY DEPARTMENT
DALLAS TX
75203-1201
US

V. Phone/Fax

Practice location:
  • Phone: 214-947-8181
  • Fax: 708-327-2620
Mailing address:
  • Phone: 214-947-8181
  • Fax: 708-327-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberT4227
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036.132976
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberT4227
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: