Provider Demographics
NPI:1063698967
Name:KATHIRESAN, KARTHIKEYANI (MD)
Entity type:Individual
Prefix:DR
First Name:KARTHIKEYANI
Middle Name:
Last Name:KATHIRESAN
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:PO BOX 1658
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78296-1658
Mailing Address - Country:US
Mailing Address - Phone:254-526-2343
Mailing Address - Fax:254-526-1084
Practice Address - Street 1:2301 S CLEAR CREEK RD #106
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4110
Practice Address - Country:US
Practice Address - Phone:254-526-2343
Practice Address - Fax:254-526-1084
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP2002029780207R00000X
TXM87532084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198006202Medicaid
TXP00656760Medicare PIN
TX198006202Medicaid
TX8L4799Medicare PIN