Provider Demographics
NPI:1427050780
Name:SURESH N GADASALLI M D P A
Entity type:Organization
Organization Name:SURESH N GADASALLI M D P A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:NAGARAJ
Authorized Official - Last Name:GADASALLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-580-5891
Mailing Address - Street 1:PO BOX 362
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-0362
Mailing Address - Country:US
Mailing Address - Phone:432-580-5891
Mailing Address - Fax:432-582-2302
Practice Address - Street 1:500 E 4TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5110
Practice Address - Country:US
Practice Address - Phone:432-580-8686
Practice Address - Fax:432-580-8383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5765207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081068102Medicaid
TX081068102Medicaid