Provider Demographics
NPI:1396798211
Name:KADESKY, KEITH T (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:T
Last Name:KADESKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 GASTON AVE STE 1205
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1812
Mailing Address - Country:US
Mailing Address - Phone:214-692-8262
Mailing Address - Fax:214-696-4190
Practice Address - Street 1:8230 WALNUT HILL LN
Practice Address - Street 2:SUITE 700
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4482
Practice Address - Country:US
Practice Address - Phone:214-691-1902
Practice Address - Fax:214-987-1845
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6326208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
80408XOtherBCBS PROVIDER ID
TX340016195OtherRRMCR
TX118932602Medicaid
TX118932601Medicaid
TX340016190OtherRR MCR
TX340016190OtherRR MCR
TX86990KMedicare PIN
TX118932601Medicaid