Provider Demographics
NPI:1396142774
Name:NORTH TEXAS GASTROENTEROLOGY, PA
Entity type:Organization
Organization Name:NORTH TEXAS GASTROENTEROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GASTROENTEROLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAYA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DASARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-338-5657
Mailing Address - Street 1:3304 COLORADO BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-6877
Mailing Address - Country:US
Mailing Address - Phone:940-898-7488
Mailing Address - Fax:940-243-3554
Practice Address - Street 1:3304 COLORADO BLVD STE 205
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6877
Practice Address - Country:US
Practice Address - Phone:940-898-7488
Practice Address - Fax:940-243-3554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-01
Last Update Date:2017-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1604207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX363459401Medicaid