Healthcare Provider Details

I. General information

NPI: 1821346263
Provider Name (Legal Business Name): JYOTSNA KUPPANNAGARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S HIGHWAY 78 STE 106
WYLIE TX
75098-3915
US

IV. Provider business mailing address

303 S HIGHWAY 78 STE 106
WYLIE TX
75098-3915
US

V. Phone/Fax

Practice location:
  • Phone: 940-381-1501
  • Fax: 972-801-9015
Mailing address:
  • Phone: 361-944-1190
  • Fax: 972-429-5410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ2680
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: