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General NPI Number Information
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NPI Number | 1578033254
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Entity Type | Individual
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Provider Name | NIBU JACOB MALAICKAL REEGT, RPSGT,RNCST
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Gender | Male
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Dates
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Enumeration Date | 11/26/2018
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Last Update Date | 11/26/2018
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Provider Practice Location Address
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Address Line | 304 S COPPELL RD
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City | COPPELL
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State | TX
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Zip | 75019-2417
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Country | US
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Telephone | 214-686-9393
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Fax |
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Provider Business Mailing Address
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Address Line | 304 S COPPELL RD
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City | COPPELL
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State | TX
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Zip | 75019-2417
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Country | US
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Telephone | 214-686-9393
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 273100000X
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Taxonomy Name | Epilepsy Hospital Unit
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License Number | 138
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License Number State |
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Taxonomy #2
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Taxonomy Code | 246ZE0500X
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Taxonomy Name | EEG Specialist/Technologist
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License Number | 4499
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License Number State |
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Taxonomy #3
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Taxonomy Code | 246ZE0600X
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Taxonomy Name | Electroneurodiagnostic Specialist/Technologist
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License Number | 878
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QS1200X
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Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
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License Number | 16863
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License Number State |
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