Provider Demographics
NPI:1336246636
Name:ISSAC, PARAMPOTTIL THARIAN (TECH)
Entity type:Individual
Prefix:
First Name:PARAMPOTTIL
Middle Name:THARIAN
Last Name:ISSAC
Suffix:
Gender:M
Credentials:TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4124 GUS THOMASSON ROAD
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2226
Mailing Address - Country:US
Mailing Address - Phone:972-682-0484
Mailing Address - Fax:
Practice Address - Street 1:4124 GUS THOMASSON ROAD
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2226
Practice Address - Country:US
Practice Address - Phone:972-682-0484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX247100000X, 2471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX459840OtherBCBS
TX459840Medicare PIN