Provider Demographics
NPI:1104949460
Name:BASOOR, KALPANA KUMARI (MD)
Entity type:Individual
Prefix:
First Name:KALPANA
Middle Name:KUMARI
Last Name:BASOOR
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 4207
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-4207
Mailing Address - Country:US
Mailing Address - Phone:903-331-0506
Mailing Address - Fax:903-331-0462
Practice Address - Street 1:700 E MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5580
Practice Address - Country:US
Practice Address - Phone:903-315-1488
Practice Address - Fax:903-315-1656
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0636207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTIN PLUS 042OtherTRICARE
TXP00644292Medicare PIN
TX8BC074OtherBCBS
TX8L2137Medicare Oscar/Certification
TX196375301Medicaid