Healthcare Provider Details

I. General information

NPI: 1639188147
Provider Name (Legal Business Name): KALYAN KUMAR RATH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1273 S PEACHTREE
JASPER TX
75951
US

IV. Provider business mailing address

1273 S PEACHTREE ST
JASPER TX
75951-4915
US

V. Phone/Fax

Practice location:
  • Phone: 409-384-9200
  • Fax: 409-384-9205
Mailing address:
  • Phone: 409-384-9200
  • Fax: 409-384-9205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK1016
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberK1016
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: