Provider Demographics
NPI:1740162726
Name:SOUTHLAKE ORTHOPEDICS & SPORTS MEDICINE, PLLC
Entity type:Organization
Organization Name:SOUTHLAKE ORTHOPEDICS & SPORTS MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BANTOO
Authorized Official - Middle Name:
Authorized Official - Last Name:SEHGAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-678-9578
Mailing Address - Street 1:800 12TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2519
Mailing Address - Country:US
Mailing Address - Phone:214-631-9881
Mailing Address - Fax:
Practice Address - Street 1:1149 KELLER PKWY STE A
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-1620
Practice Address - Country:US
Practice Address - Phone:214-631-9881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-22
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty