Provider Demographics
NPI:1871579276
Name:KUKKALLI, BHUSHAN (MD)
Entity type:Individual
Prefix:
First Name:BHUSHAN
Middle Name:
Last Name:KUKKALLI
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 1:5221 PINE ST
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-4820
Mailing Address - Country:US
Mailing Address - Phone:713-669-0807
Mailing Address - Fax:713-669-0807
Practice Address - Street 1:6565 FANNIN ST.
Practice Address - Street 2:METHODIST HOSPITAL
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:972-393-1140
Practice Address - Fax:972-393-7933
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2391207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148071705Medicaid
TX148071703Medicaid
TX8F8317OtherBCBSTX PROV NO
TX148071703Medicaid
TX8A5418Medicare PIN
TX8L24366Medicare PIN
TX930116937Medicare PIN
TX8F8317OtherBCBSTX PROV NO
TX148071705Medicaid