1629258058 NPI number — DALLAS GERIATRICS ASSOCIATES, P.A

Table of content: (NPI 1629258058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629258058 NPI number — DALLAS GERIATRICS ASSOCIATES, P.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DALLAS GERIATRICS ASSOCIATES, P.A
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:
1629258058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
445 E. FM 1382
Provider Second Line Business Mailing Address:
SUITE # 3354
Provider Business Mailing Address City Name:
CEDAR HILL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-900-0747
Provider Business Mailing Address Fax Number:
972-393-5234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 SHEPHERD LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALCH SPRINGS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75180-3423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-325-1969
Provider Business Practice Location Address Fax Number:
972-291-0019
Provider Enumeration Date:
11/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PRASAD
Authorized Official First Name:
JYOTSNA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
972-900-0747

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X , with the licence number:  J6213 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00Y540 . This is a "GROUP PTAN/ DALLAS COUNTY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: H75575 . This is a "MEDICARE UPIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: L5100 . This is a "TEXAS MEDICAL LICENSE #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00Y542 . This is a "GROUP PTAN/ TARRANT COUNTY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00Y541 . This is a "GROUP PTAN/ ELLIS & TARRANT COUNTY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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