Healthcare Provider Details

I. General information

NPI: 1871579276
Provider Name (Legal Business Name): BHUSHAN KUKKALLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 03/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 FANNIN ST. METHODIST HOSPITAL
HOUSTON TX
77030
US

IV. Provider business mailing address

5221 PINE ST
BELLAIRE TX
77401-4820
US

V. Phone/Fax

Practice location:
  • Phone: 972-393-1140
  • Fax: 972-393-7933
Mailing address:
  • Phone: 713-669-0807
  • Fax: 713-669-0807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberL2391
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: