Basic Information
| Provider Information | |||||||||
| NPI: | 1396798211 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KADESKY | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 GASTON AVE STE 1205 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146928262 | ||||||||
| FaxNumber: | 2146964190 | ||||||||
| Practice Location | |||||||||
| Address1: | 8230 WALNUT HILL LN | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752314482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146911902 | ||||||||
| FaxNumber: | 2149871845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | H6326 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 80408X | 01 | BCBS PROVIDER ID | OTHER | 340016195 | 01 | TX | RRMCR | OTHER | 118932602 | 05 | TX | MEDICAID | 118932601 | 05 | TX | MEDICAID | 340016190 | 01 | TX | RR MCR | OTHER |