Basic Information
Provider Information | |||||||||
NPI: | 1942411889 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NAIR | ||||||||
FirstName: | AMBIKA | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NAIR | ||||||||
OtherFirstName: | AMBIKA | ||||||||
OtherMiddleName: | KUMARI | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1227 WOODSEY CT | ||||||||
Address2: |   | ||||||||
City: | SOUTHLAKE | ||||||||
State: | TX | ||||||||
PostalCode: | 760929758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8174161467 | ||||||||
FaxNumber: | 2145406627 | ||||||||
Practice Location | |||||||||
Address1: | 1617 HEMPHILL STREET | ||||||||
Address2: |   | ||||||||
City: | FORTWORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761047911 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8179271395 | ||||||||
FaxNumber: | 8179273603 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2007 | ||||||||
LastUpdateDate: | 06/19/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | N1794 | TX | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
ID Information
ID | Type | State | Issuer | Description | 8L17376 | 01 | TX | MEDICARE PROVIDER NUMBER | OTHER | 206145901 | 05 | TX |   | MEDICAID |