1962823955 NPI number — DR. VAMSEEN JETTI PA

Table of content: (NPI 1962823955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962823955 NPI number — DR. VAMSEEN JETTI PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. VAMSEEN JETTI 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:
1962823955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3610 GILLESPIE ST
Provider Second Line Business Mailing Address:
#3
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75219-4839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-505-3884
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6200 W PARKER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-8185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-668-7460
Provider Business Practice Location Address Fax Number:
972-668-7467
Provider Enumeration Date:
12/18/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JETTI
Authorized Official First Name:
VAMSEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
202-505-3884

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  P6981 , 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)

  • Identifier: P6981 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".