Provider Demographics
NPI:1073915245
Name:TEXAS RADIATION ONCOLOGY MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:TEXAS RADIATION ONCOLOGY MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AJMEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PUTHAWALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-962-1700
Mailing Address - Street 1:2865 E COAST HWY
Mailing Address - Street 2:200
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2236
Mailing Address - Country:US
Mailing Address - Phone:949-385-5012
Mailing Address - Fax:
Practice Address - Street 1:2800 STATE HWY 114 EAST
Practice Address - Street 2:SUITE 100
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76262
Practice Address - Country:US
Practice Address - Phone:817-693-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty