Provider Demographics
NPI:1497858435
Name:SHASHIKUMAR, KAVITHA (MD)
Entity type:Individual
Prefix:DR
First Name:KAVITHA
Middle Name:
Last Name:SHASHIKUMAR
Suffix:
Gender:
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 16387
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76162-0387
Mailing Address - Country:US
Mailing Address - Phone:817-294-1408
Mailing Address - Fax:
Practice Address - Street 1:6528 SAUCON VALLEY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-5452
Practice Address - Country:US
Practice Address - Phone:817-819-4919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA100265207RI0200X, 2083P0011X
TXL5558207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154604602Medicaid
TXH72665Medicare UPIN
TX8B7779Medicare ID - Type Unspecified