Healthcare Provider Details

I. General information

NPI: 1053382754
Provider Name (Legal Business Name): PRAKASH HEGDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 04/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11803 SOUTH FWY STE 201
BURLESON TX
76028-7029
US

IV. Provider business mailing address

11803 SOUTH FWY STE 201
BURLESON TX
76028-7029
US

V. Phone/Fax

Practice location:
  • Phone: 817-293-4800
  • Fax: 817-293-4808
Mailing address:
  • Phone: 817-293-4800
  • Fax: 817-293-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL7415
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: