Provider Demographics
NPI:1427804244
Name:PHILLIP, INDARANI
Entity type:Individual
Prefix:
First Name:INDARANI
Middle Name:
Last Name:PHILLIP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7659 ASPEN PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-4268
Mailing Address - Country:US
Mailing Address - Phone:210-748-1899
Mailing Address - Fax:
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:903-315-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program