1205023397 NPI number — INTERNAL MEDICINE ASSOCIATES OF SOUTH DALLAS PA

Table of content: (NPI 1205023397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205023397 NPI number — INTERNAL MEDICINE ASSOCIATES OF SOUTH DALLAS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE ASSOCIATES OF SOUTH DALLAS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1205023397
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4305 W WHEATLAND RD
Provider Second Line Business Mailing Address:
SUITE NUMBER 101
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75237-3303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-697-7985
Provider Business Mailing Address Fax Number:
972-708-9498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4305 W WHEATLAND RD
Provider Second Line Business Practice Location Address:
SUITE NUMBER 101
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75237-3303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-697-7985
Provider Business Practice Location Address Fax Number:
972-708-9498
Provider Enumeration Date:
10/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SRIVASTAVA
Authorized Official First Name:
ASHWANI
Authorized Official Middle Name:
DAYAL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-697-7985

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  L3488 , 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)





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