Provider Demographics
NPI:1063657740
Name:SAMBATHKUMAR, LAKSHMI (MD)
Entity type:Individual
Prefix:
First Name:LAKSHMI
Middle Name:
Last Name:SAMBATHKUMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W TERRELL AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2820
Mailing Address - Country:US
Mailing Address - Phone:817-820-4906
Mailing Address - Fax:817-820-4815
Practice Address - Street 1:1025 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3013
Practice Address - Country:US
Practice Address - Phone:817-871-9069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1122207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203473802Medicaid
TX8L12178Medicare PIN