Provider Demographics
NPI:1023348299
Name:SAMPATH, PRAVEEN KUMAR (MD)
Entity type:Individual
Prefix:DR
First Name:PRAVEEN
Middle Name:KUMAR
Last Name:SAMPATH
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 1:4101 PERCHERON BND
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7881
Mailing Address - Country:US
Mailing Address - Phone:716-907-1096
Mailing Address - Fax:512-324-4332
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-11
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME117230207RG0100X
AZ55431207RG0100X
TXQ2845207RG0100X
IL036164435207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3463192-02Medicaid
TX3463192-02Medicaid
TX413928YQYYMedicare PIN
FL010353700Medicaid