1104921642 NPI number — JOHN A KUNNATHUSSERIL MAMTH

Table of content: JOHN A KUNNATHUSSERIL MAMTH (NPI 1104921642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104921642 NPI number — JOHN A KUNNATHUSSERIL MAMTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUNNATHUSSERIL
Provider First Name:
JOHN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MAMTH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104921642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 SIMMONS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COPPELL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-462-8246
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4525 LEMMON AVE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-526-4525
Provider Business Practice Location Address Fax Number:
214-520-6468
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  7675 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 2886 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 148198 . This is a "VALUE OPTION NORTH STAR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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