Provider Demographics
NPI:1104243104
Name:TALAGADADEEVI, KISHAN PRASAD
Entity type:Individual
Prefix:DR
First Name:KISHAN PRASAD
Middle Name:
Last Name:TALAGADADEEVI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5725
Mailing Address - Country:US
Mailing Address - Phone:337-436-2511
Mailing Address - Fax:
Practice Address - Street 1:1600 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6913
Practice Address - Country:US
Practice Address - Phone:817-848-2708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA305972208M00000X
390200000X
TXT5786207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program